Travel Accident 2024-2025 – School Employee Enrollment Form

Pennsylvania School Boards Association: Policyholder
49937: Master Policy No.

School entity *

Submitted by *

First

Last

Email *

Phone number *

You can enroll up to 25 employees at a time. If you need to enroll more than 25, please fill out a second form. Once you complete one enrollment line, more will appear below.

Employee name *

First

Last

Employee title *

Signature *

Clear Signature

Date *

The total cost will be calculated to proceed with payment. If you prefer, you may submit the form online (bypassing the credit card step) and mail payment to:

PSBA Insurance
400 Bent Creek Blvd.
Mechanicsburg, PA 17050

Total

$0.00

Credit card