Application for Coverage

1.

Entity Name

*This question is required.

2.

Contact First Name

*This question is required.

3.

Contact Last Name

*This question is required.

4.

Contact Email

*This question is required. This question requires a valid email address.

6.

Average Daily Attendance

*This question is required.

6.

Annual Budget

*This question is required.

6.

Estimated Total Annual Payroll

*This question is required.

6.

Estimated Number of Full-time Employees

*This question is required.

6.

Coverage Effective Date

*This question is required. This question requires a valid date format of MM/DD/YYYY.

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7.

Date Proposal Needed

*This question is required. This question requires a valid date format of MM/DD/YYYY.

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8.

If your ADA or budget is expected to change by more than 5 percent next fiscal year, please provide details:

*This question is required.

9.

If your district is engaged in any non-traditional school business activities, including but not limited to airstrips, recreational facilities, daycare, police, or security forces, please provide details:

*This question is required.