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School Intake Form

Your Information Full Name:* Email:* Phone:*

School Information

In partnership with Alliant Insurance Services.

Alliant agent name:

School or District Name:* Address 1:* Address 2: City:* State:* Zip:* School District Affiliate Name: # of Schools in District: School District Funding for 2025/2026 Budget: Are you a member of an Insurance Pool, Joint Powers Authority, or similar? Yes No If Yes, Name: Do you have a "Banked Days Policy"? Yes No Paid Time Off (PTO) Allowance (avg# of days): Paid Sick Days Allowance (avg# of days): Maternity/Paternity/Adoption Policy (avg# of days):

Absence Data Number of FTE’s to be covered:

Please check all staff categories you wish to be covered:

Certified Teaching Staff Non-certified Teaching Staff Administrators Office Staff Maintenance Staff Transportation Staff Safety/Security Staff Technology Nurses Other (please specify):

Coverage Options Please advise if you wish coverage to be provided for: Paid Time Off (PTO) Unpaid Leave Banked Days Daily Substitute Costs to be Reimbursed

Absence Data Upload

Regarding the individuals for whom you require coverage, please provide at least 3-5 years of absence data including:

Staff Member Name
Staff Member Category
Reason for Absence
Number of Hours/Days of Absence
Condition/Reason for Absence

Please upload your data here:

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