MCR2 District Student Accident Form
The Montgomery County R-II School District has purchased and made available to all students Prekindergarten through 12th Grade Accident Insurance.

This Accident Insurance will cover accidents to any student while engaged in school activities and under a school employee supervision.  This includes in class, recess, field trips, clubs, organizations, etc.

This Accident Insurance is not to be confused with the MSHSAA Activities Student Accident Insurance.  The insurance referred to in this section is for accidents which occur outside of MSHSAA Activities.

The form for submitting claims can be downloaded at the end of this page.

If a student involved in an accident has other insurance coverage, this insurance is secondary and will not pay until all claims have been submitted to the primary insurance and settled.  If a student does not have any insurance for an accident, this insurance becomes primary and will pay for claims.

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 in a school sponsored class or 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


MCR2 District Student Accident Insurance Form