MCR2 District MSHSAA Activities Accident Insurance

You may download the Montgomery County R-II School District purchased MSHSAA Activities Accident Insurance Form below.

You may also download information on coverage and amounts of coverage by clicking on the MCR2 MSHSAA Student Accident Information link below.

Some suggestions:

  1. The form must be signed by a School Official at the bottom of Part I-A.  Building Principals, Activities Director, Assistant Superintendent and Superintendent are the only school officials that are allowed to sign this form.  By our signature we are attesting that the accident occurred while the student was participating in an approved MSHSAA activity.
  2. Part I-B must be completed in full by the Parent or Legal Guardian of the student.
  3. Part II of the form is to be completed by the attending physician.  You may desire to download a form prior to the physician visit, have the attending physician fill out Part II, then have the school official sign and complete any of their portion in Part I-A.  You may certainly have these sections completed in any order you choose.
  4. The forms must be completed within 90 days of the date of treatment.
  5. If you have personal insurance, costs for any claims must be submitted to your personal insurance company first.

  6. Once completed send the completed form along with any and all itemized bills to:

Lawrence E. Smith& Associates
P.O. Box 411216
St. Louis, MO   63141
(636) 532-1660
(800) 325-1350

 

 

Link to MCR2 District MSHSAA Accident Insurance Form

Link to MCR2 District MSHSAA Accident Insurance Information