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School of Health Education Student Accident Insurance Form

All School of Health Education programs require students to have basic health/accident insurance for clinical participation. By checking yes on the Health History form or on Certifiedbackground.com, you are indicating that you agree to maintain coverage throughout the duration of your clinical experience(s) and that you understand that Madison College cannot assume any liability or financial obligation for students’ health care.

If you are in need of a low-cost basic accident insurance plan while enrolled in core School of Health Education clinical courses, more details can be found on Gallagher Koster's website. The cost is $13 per semester and the non-refundable fee will be posted to your Madison College student financial account.

If you want to receive Student Accident Insurance and have read all of the information at Gallagher Koster's website, please fill out this form to be enrolled.

Upon submission of the form, you will immediately receive a confirmation email confirming your submission. Within approximately two weeks, you will receive an email directly from Gallagher Koster regarding your next steps on how to activate your account and get your insurance card.

Please submit this form no sooner than one month prior to term start.

You must submit a new form for each term in which you are requesting insurance.

Please enter your telephone number in this format: 6081234567
Spring Term 2015: January 2, 2015
Spring Term 2015: June 19, 2015