Charter School Application
     Before coverage can be effective, the SELF office must have:
1.
2.
A signed SELF JPA Agreement
A copy of your Board's action authorizing participation in SELF

General Information
Name Of School 
Mailing Address 
City 
State 
Zip
Name Of District 
County 
Contact Person 
Title
Telephone 
Fax 
E-mail 
Alternate Contact Person
Title
Average Daily Attendance 
Date Coverage Requested To Be Effective 
Primary JPA 

Invoice To  School District JPA
 
Underlying Insurance
School's Self Insured Retention (Deductible) $1.00 to $
Insurance Company/JPA Name 
Policy Dollar Limit $
 to $
Insurance Company/JPA Name 
Policy Dollar Limit $
 to $
 
Claims Administration
 Is Claims Administration Done In-house? 
 Yes No
If No, Name of Administration Agency 
Agency Address 
Contact Person 
Contact Phone 
 
Loss Prevention
Does The School Have A Formal Loss Prevention Program? 
 Yes No
If Yes, Is The Program Administered By Internal Staff? Yes No
If No, Name Of External Provider 
External Provider Contact 
External Provider Phone 
External Provider E-mail 
 
Number Of Campuses
Elementary Schools 

Junior High Schools 
High Schools 
Other Sites 

 
 Number Of Vehicles
Type 1 Buses (60 - 90 Passengers) 

Type 2 Buses (24 - 28 Passengers) 
Other Vehicles 
 
Repair Classes
Does The School Provide Auto Repair Classes?
Yes No
Does The School Provide Aircraft Repair Classes?
Yes No
 
Location
Classify The School Location  Urban Suburban Rural