Voluntary K-12 Student Insurance Plans Parent Letter 2016 – 2017

Denton ISD has contracted with Texas Student Resources/Health Special Risk (HSR), Inc. to administer the

student accident insurance program for the 2016 – 2017 school year.

This voluntary supplemental coverage offered is very affordable and is available to any student enrolled at

Denton ISD for a single low annual premium payment. Parents may enroll online at

www.K12StudentInsurance.com. Additional information can be found at www.dentonisd.org, departments,

Athletics or Student Support Services webpage.

All enrollment, coverage and payments are handled entirely by HSR. Below are the three (3) plan options

that are available to parents through HSR:

Option A - 24-Hour Coverage excluding High School Football:

Coverage is provided at all times except while participating in any activity, including tryouts, practice or any

competitions or games for high school football.

Option B - School plus Interscholastic Athletics & Activities excluding High School Football:

Coverage is provided during:

1. Regularly scheduled classroom instruction;

2. Regularly scheduled and supervised recess or lunch period;

a study period or special instruction period supervised by a member of the School's faculty;

3. Supervised and Sponsored School Activity;

4. Covered School Travel. Coverage is also provided during School sponsored interscholastic sports and

activities. High school football is not covered.

Option C - High School Football only:

Coverage is provided during:

1. Regularly scheduled practice or training;

2. Regularly scheduled competition or exhibition game;

3. Scheduled tryout, workout session or team meeting;

4. Sponsored Sports Covered Activity.

In accordance with the Texas Tort Claims Act § 101.021 and §101.051, Denton ISD is not legally

responsible for costs of treating student injuries or assume liability for any other costs associated with an

injury at school or any school related function (except for limited liability for negligent operation and use of a

motorized vehicle) performing district duties. Please note that any medical doctor or facility charges above

the policy limits are ultimately the parents/guardians responsibility. There is no guarantee that all medical

expenses will be covered.

For additional information please call: 1-866-409-5733.

2016-2017 TEXAS K-12 VOLUNTARY PLANS SCHEDULE OF BENEFITS

Coverage underwritten by Starr Indemnity & Liability Company, Dallas, TX

Coverage is provided for loss due to a covered injury up to a maximum per injury benefit amount of $25,000 ($5,000 for Motor Vehicle Injuries). Treatment of covered injuries must begin within 60 days of the accident date. Only eligible expenses incurred within 52 weeks from the date of the accident are covered. The maximum benefit amount per service/treatment is as shown below. Benefits will be paid only for such expense which is not recoverable from any other insurance policy, service contract or workers' compensation.

INPATIENT: PREMIER VOLUNTARY PLAN ECONOMY VOLUNTARY PLAN

Room & Board Semi-Private Room Rate Semi-Private Room Rate

Intensive Care 1.5 times the Semi-Private Room Rate 1.5 times the Semi-Private Room Rate

Hospital Miscellaneous Up to $250 per day, to a maximum of $5,000 Up to $250 per day, to a maximum of $4,000

Registered Nurse Up to $400 per injury Up to $400 per injury

Physician’s Nonsurgical Visits Up to $40 per visit Up to $20 per visit

(Benefits are limited to one visit per day and do not apply when related to surgery)

Orthopedic Braces and Appliances Included in Hospital Miscellaneous Benefit Included in Hospital Miscellaneous Benefit

OUTPATIENT:

Hospital Outpatient Surgery – Facility Charge Up to $1,250 per injury Up to $750 per injury

Physician’s Nonsurgical Visits Up to $40 per visit Up to $20 per visit

(Benefits are limited to one visit per day and do not apply when related to surgery or physiotherapy)

Physiotherapy Up to $20 per visit, to a $100 maximum (Benefits are limited to one visit per day)

Up to $20 per visit, to a $40 maximum (Benefits are limited to one visit per day)

Emergency Room Up to $150 per injury Up to $75 per injury

(Use of room and supplies; treatment must be rendered within 72 hours from time of injury)

Physician Emergency Room Up to $60/injury Up to $40/injury

X-Ray Services (includes charges for reading) Up to $200 per injury Up to $100 per injury

Cat Scan/MRI Services (includes charges for reading)

Up to $500 per injury Up to $250 per injury

Laboratory Up to $50 per injury Up to $25 per injury

Injections Up to $25 per injury Up to $25 per injury

Prescription Drugs 100% of Allowable Expense 100% of Allowable Expense

Orthopedic Braces and Appliances Up to $300 per injury (When prescribed by a physician for healing)

Up to $300 per injury (When prescribed by a physician for healing)

Durable Medical Equipment (Post Surgical Only)

Up to $150 per injury Up to $150 per injury

INPATIENT AND/OR OUTPATIENT:

Surgeon’s Fees 75% of Allowable Expense up to a $3,750 maximum (Limited to the primary procedure per surgery)

75% of Allowable Expense up to a $3,500 maximum (Limited to the primary procedure per surgery)

Anesthetist/Assistant Surgeon 25% of surgeon’s allowance 25% of surgeon’s allowance

Ambulance 100% of Allowable Expense, first trip to the hospital

First trip to the hospital up to a $100 maximum

Treatment of Heat Exhaustion 100% of Allowable Expense 100% of Allowable Expense

Dental Up to $250 per tooth (Benefits are paid on sound natural teeth only)

Up to $150 per tooth (Benefits are paid on sound natural teeth only)

Replacement of Eyeglasses, Contact Lenses & Hearing Aids

100% of Allowable Expense for replacement if broken due to injury

100% of Allowable Expense for replacement if broken due to injury

Extended Dental Coverage This is supplemental coverage for expenses resulting from covered accidental injuries. The dental benefits provided are: (a) 100% of Allowable Expense for examinations, X-Rays, endodontics and oral surgery to a maximum of $10,000 and (b) dental expenses toward the cost of bridges, dentures or replacement of previous dental repairs to a maximum of $250. No coverage is provided for orthodontics (braces) for any reason or damage or loss thereof.

This document provides only a brief description of the coverage provided. The policy contains full details of the coverage including definitions, limitations and exclusions. In the event of a conflict between the policy and this document, the policy shall be the governing document.

THIS IS A LIMITED BENEFIT POLICY

Voluntary Student Accident Insurance

Health Special Risk, Inc.HSR Plaza II 4100 Medical Parkway Carrollton, TX 75007 - 1517

Phone: 866.409.5733, Ext. 5660 Fax: 972.512.5819 www.healthspecialrisk.com

HSR is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Starr Companies .

Coverage underwritten by: Starr Indemnity & Liability, Dallas, TX

TEXAS 2016-2017

K-12 Voluntary Student Accident Insurance Coverage

Policy Form AH-20001

Coverage underwritten by: Starr Indemnity & Liability, Dallas, TX

Eligibility

All registered students of a participating school/district in grades Pre K-12.

Coverages

Option A: 24 Hour excluding High School Football: Coverage is provided at all times except while participating in any activity, including

tryouts, practice or any competitions or games for high school football.

Option B: School plus Interscholastic Athletics & Activities excluding High School Football: Coverage is provided during 1. Regularly

scheduled classroom instruction; 2.regularly-scheduled and supervised recess or lunch period; 3.a study period or special instruction period

supervised by a member of the School's faculty; 4.a Supervised and Sponsored School Activity; or 5. Covered School Travel. Coverage is

also provided during School sponsored interscholastic sports and activities. High school football is not covered.

Option C: High School Football only: Coverage is provided during: 1. regularly-scheduled practice or training; 2. regularly-scheduled

competition or exhibition game; 3.a scheduled tryout, workout session or team meeting; 4. a Sponsored Sports Covered Activity; or 5.

Covered Sports Travel.

Benefits Accident Medical Expense: When a covered injury to an Insured Person results in treatment by a Physician or surgeon beginning within 60 days of the

date of the covered accident; we will pay benefits, in excess of the Deductible, if any. Eligible Medical expenses must be incurred by the Insured Person

within 52 weeks from the date of the covered accident are covered. Benefits for any one accident shall not exceed the Accidental Medical Expense

Maximum of $25,000.

Eligible medical expenses include • Room and board in a semi-private Private room;

• Hospital Miscellaneous Services;

• Physician services, Surgery, Assistant Surgeon, Physician’s Surgical Facilities, Second Opinion, or consultation, Anesthesia and it

administration, In Physician Hospital Visits, Physician Office visits;

• Emergency Room;

• Outpatient Services;

• Outpatient X Ray, CT Scan, MRI, and Laboratory Test includes charges for reading;

• Outpatient physiotherapy;

• Orthopedic Appliances

• Ambulance Services: one trip to the nearest Hospital by air or ground;

• Dental Services provided by a Dentist or Physician;

• Outpatient prescription drugs;

• Eyeglasses, Contacts lenses and Hearing Aids;

• Medical equipment rental or if less than the purchase of equipment;

• Hernia;

Full Excess Medical Expense: The Company will pay Covered Expenses only when they are in excess of amounts payable by any Other Insurance whether

or not claim has been made for benefits it provides. Other Insurance means any reimbursement for or recovery of any element of Covered Injury as a result

of an Accident available from any other source whatsoever, except gifts and donations, but including without limitations:

• Any individual, group, blanket or franchise policy of Accident, disability or health insurance or any similar type of arrangement that provides for payments or reimbursement of medical expenses or disability payments;

• Social Security Disability Benefits; and any benefits payable under any program provided or sponsored solely or primarily by and federal, state or local governmental unit or agency or subdivision or through operation of law or regulation; except Medicaid If the Policyholder provides mandatory coverage for students under another program, benefits will be payable under those programs before being considered under the voluntary policy.

Deferred Dental Treatment Expense (Available only when selected): Deferred Dental Expenses are Covered Expenses for treatment, including X-rays, to

repair injury to a tooth (1) with no fillings or cavities or only fillings or cavities that do not undermine the tooth cusps; and (2) for which pulpal tissues are

healthy and intact; and (3) for which periodontal tissue shows little or no signs of active or chronic inflammation; or to the supporting structures of the

teeth of the Insured Person. If there is more than one way to treat a dental problem, the Company will pay based on the least expensive procedure if that

procedure meets commonly accepted standards of the American Dental Association. No coverage is provided for orthodontics for any reason or damage

or loss thereof.

Dental x-rays, endodontic and Oral Surgery are covered up to $10,000 per Covered Injury. Bridges, dentures or replacement of dental repairs are

covered up to $250 per Covered Injury. The benefit period for this benefit is 52 weeks.

Accidental Death, Dismemberment, or Loss of Sight, Speech or Hearing: We will pay the benefit amounts shown for Accidental Death,

Dismemberment or Loss of Sight, Speech or Hearing which results solely from an injury to the Insured Person which occurs during a covered activity,

and from no other contributory cause, and is sustained within 180 days after the date of the injury. If an Insured Person sustains more than one such

loss as the result of one Covered Accident, we will pay only one amount, the largest to which he or she is entitled. This amount will not exceed the

Principal Sum that applies for the Insured Person.

Loss of Life $2,000

Loss of Two or More Hands or Feet $10,000

Loss of Sight of Both Eyes $10,000

Loss of Speech and Hearing (in Both Ears) $10,000

Loss of One Hand or Foot and Sight in One Eye $10,000

Loss of One Hand or Foot $5,000

Loss of Sight in One Eye $5,000

Loss of Speech $5,000

Loss of Hearing (in Both Ears) $5,000

Loss of Thumb and Index Finger of the Same Hand $500

Definitions Covered Accident means a sudden, unexpected, specific and abrupt event that results directly and independently of all other causes, in a Covered Injury

or Covered Death and meets all of the following conditions: 1. occurs while the Insured Person's coverage under the Policy is in force; 2.occurs while the

Insured Person is attending, participating in or traveling to and from a Covered Activity; and 3. is not otherwise excluded under the terms of the Policy.

Covered Death means Accidental death: 1.which is the direct result of a Covered Accident; 2.which results directly and independently from all other causes

from a Covered Accident and independent of Sickness, disease, mental incapacity, bodily infirmity or any other cause; and 3.suffered by the Insured Person

within the applicable time period specified in the Schedule of Benefits.

Covered Injury means Accidental bodily injury: 1.which is sustained by an Insured Person as a direct result of a Covered Accident that is external to the

body; 2.which results directly and independently from all other causes from a Covered Accident (independent of Sickness, disease, mental incapacity,

bodily infirmity or any other cause) that causes a Covered Loss; and 3.suffered by the Insured Person within the applicable time period specified in the

Schedule of Benefits. The Covered Injury must be caused through Accidental means. All injuries sustained by an Insured Person in any one Accident,

including related conditions and recurrent symptoms of these injuries, are considered a single injury.

Covered Loss means a loss which results from a Covered Injury or Covered Death, and for which benefits are payable under the Policy. Covered Loss

includes any expenses arising from services or supplies rendered or obtained by the Insured Person when such services and supplies are covered by the

Policy.

Loss of a Hand or Foot means complete Severance through or above the wrist or ankle joint. Loss of Hearing means total and permanent loss of ability to

hear any sound in both ears which is irrecoverable by natural, surgical or artificial means. Loss of Sight means the total, permanent Loss of Sight of one

eye. The Loss of Sight must be irrecoverable by natural, surgical or artificial means. Loss of Speech means total and permanent loss of audible

communication which is irrecoverable by natural, surgical or artificial means. Loss of a Thumb and Index Finger of the Same Hand means complete

Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand).

Exclusions and Limitations

This Policy does not cover:

1. Intentionally self-inflicted injury, suicide, or any attempt while sane or insane; 2.Commission or attempt to commit a felony or an assault; 3. Commission

of or active participation in a riot or insurrection; 4.Declared or undeclared war or act of war or any act of declared or undeclared war unless specifically

provided by the Policy; 5.The Insured Person’s intoxication as determined according to the laws of the jurisdiction in which the Covered Loss occurred or

the laws of the Home Country; 6.Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a

Physician and taken in accordance with the prescribed dosage; 7.A Covered Loss that occurs while on active duty service in the military, naval or air force

of any country or international organization. Upon the Company’s receipt of proof of service, the Company will refund any premium paid for this time.

Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days; 8.Travel or activity outside the United States; 9.Flight in,

boarding or alighting from an Aircraft or any craft designed to fly above the Earth’s surface, except as: a. A fare-paying passenger on a regularly

scheduled commercial airline; b. A passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;

c. A passenger in a Military Aircraft flown by the Air Mobility Command or its foreign equivalent; 10. Bungee-cord jumping; parachuting; skydiving;

parasailing; hang-gliding; skiing; scuba diving; surfing; roller skating; riding in a rodeo; glider flying; flight in an ultralight aircraft; sailplaning; bob-sledding;

ballooning; fighting or brawling except in self-defense; operating, sitting or riding in or upon, alighting to or from, or working on or around any motorcycle or

recreational motor vehicle including but not limited to two or three wheeled motor vehicles, four wheeled all-terrain vehicles (ATVs), jet skis, ski cycles, or

snowmobiles; 11. Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial

infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food;12.Travel in or on any off-road motorized vehicle

that does not require licensing as a motor vehicle;13. Injuries compensable under Workers’ Compensation law or any similar law; 14. An Accident if the

Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, unless: (a) the Insured Person holds a

valid learners permit and (b) the Insured Person is receiving instruction from a driver's education instructor; In addition, benefits will not be paid for

services or treatment rendered by any person who is: employed or retained by the Policyholder; A Resident of the Same Household; An Immediate Family

Member including Domestic Partner of either the Insured Person or the Insured Person’s Spouse; the Insured Person.

Texas Voluntary Student Accident Insurance

Schedule of Benefits

ACCIDENT MEDICAL EXPENSE BENEFIT ECONOMY PREMIER

Full Excess Accident Expense Benefit Maximum $25,000 $25,000

First Covered Expenses must be received within 60 days after the Covered Injury 60 days after the Covered Injury

Benefit Period 1 year from the date of the Covered Injury 1 year from the date of the Covered Injury

Benefit Limit for Covered Injuries from any one

motor vehicle Accident $5,000 $5,000

INPATIENT HOSPITAL SERVICES

Room and Board Expenses

Semi-Private Room 100% of the Usual and Customary Charges 100% of the Usual and Customary Charges

Hospital Miscellaneous Expenses up to $250 per day, to a maximum of $4,000 per

Covered Injury up to $250 per day to a maximum of $5,000 per

Covered Injury

Emergency Room Treatment up to $75 per Covered Injury up to $150 per Covered Injury

Emergency Room Treatment must occur within 72 hours of the Covered Injury 72 hours of the Covered Injury

Registered Nursing Services up to $400 per Covered Injury up to $400 per Covered Injury

Physician Services

Surgery 75% of the Usual and Customary Charges up to

$3,500 per Covered Injury 75% of the Usual and Customary Charges up to

$3,750 per Covered Injury

Assistant Surgeon 25% of Physician’s Surgery Allowance 25% of Physician’s Surgery Allowance

Anesthesia and its Administration 25% of Physician’s Surgery Allowance 25% of Physician’s Surgery Allowance

Physician In-Hospital Non –Surgical Visits up to $20 per visit up to $40 per visit

OUTPATIENT BENEFITS

Physician Office Non- Surgical Visits up to $20 per visit up to $40 per visit

Combined Maximum for CT scan, MRI up to $250 per Covered Injury up to $500 per Covered Injury

X-ray up to $100 per Covered Injury up to $200 per Covered Injury

Laboratory tests up to $50 per Covered Injury up to $100 per Covered Injury

Outpatient Physiotherapy Benefit up to 2 treatments; up to $40 per Covered Injury; 1

visit in a day up to 5 treatments; up to $100 per Covered Injury; 1

visit in a day

Outpatient Orthopedic Appliances up to $300 per Covered Injury up to $300 per Covered Injury

Hospital Outpatient Surgery Facilities Payment up to $750 per Covered Injury up to $1,250 per Covered Injury

Ambulance Services up to $100 per Policy Year 100% of the Usual and Customary Charges

Medical Equipment up to $150 per Covered Injury up to $150 per Covered Injury

Dental Services up to $150 per Tooth up to $250 per tooth

Outpatient Prescription Drugs 100% of the Usual and Customary Charges 100% of the Usual and Customary Charges

Eyeglasses, Contact Lenses, Hearing Aids 100% of the Usual and Customary Charges 100% of the Usual and Customary Charges

AVAILABLE ONLY WHEN SELECTED

Deferred Treatment - Dental

up to $10,000 per Covered Injury; Cost of bridges,

dentures, or replacement of dental repairs up to $250

per Covered Injury; 52 week benefit period

up to $10,000 per Covered Injury; Cost of bridges,

dentures, or replacement of dental repairs up to $250

per Covered Injury; 52 week benefit period

Plan & Rate Options

without Deferred Dental with Deferred Dental

Economy Premier Economy Premier

Option A 24 Hour without HS Football $

109.00

$

167.00

$

117.00

$

175.00

Option B At School without HS Football $

54.00

$

80.00

$

62.00

$

88.00

Option C High School Football $

161.00

$

247.00

$

169.00

$

255.00

Option C Spring High School Football $

65.00

$

99.00

$

73.00

$

107.00

Note: Any 9th grade student that plays with the High School Football Team (grades 10-12) must purchase Football coverage.

2016-2017 VOLUNTARY STUDENT ACCIDENT INSURANCE

ENROLLMENT FORM

______________________ ______________________ Student’s Last Name Student’s DOB (MM-DD-YYYY)

______________________________ _____ ______________________________

Student’s First Name MI Telephone Number

______________________________ ____________ ______________________________

Student’s Social Security Number Grade Student Identification Number

______________ _________________________________________________________________

Street # Address

_____________________________ ___________________________ ___________

City State Zip Code

_____________________________ ____________________________________________

Name of School District Name of School/Campus (required to

process)

___________________________________________ __________________________

Signature of Parent/Guardian Date

___________________________________________

Email Address

Please select your Plan below:

Without Deferred Dental With Deferred Dental

Economy* Premier* Economy* Premier*

Option A 24 Hour without HS Football $109.00 $167.00 $117.00 $175.00

Option B At School without HS Football $54.00 $80.00 $62.00 $88.00

Option C High School Football $161.00 $247.00 $169.00 $255.00

Option C Spring High School Football $65.00 $99.00 $73.00 $107.00

Company Use ONLY:

Check #:

____________________________________

Amt Rec’d: __________________________

Enclose check for total amount payable to: Health Special Risk

TOTAL All Selections HERE:

_______________________________

* There is a $1.00 administration fee due with each paper enrollment form submission.

Once completed, mail this form to:

Health Special Risk, Inc.

P.O. Box 674239 Dallas, TX 75267-4239

For more information or assistance regarding all Student Insurance, contact our Customer Service Department at 866-243-7885.

IF YOU WISH TO PAY WITH MASTERCARD OR VISA**: Go to www.K12StudentInsurance.com **A 5% administrative charge will be added for Credit Card Orders

FACTS ABOUT THE POLICY 1. POLICIES ARE ONE YEAR RENEWABLE TERM. 2. 30 DAY RIGHT TO EXAMINE POLICY: If you are not satisfied

with this Policy for any reason, return it to us within 30 days after you receive it. Any premium paid will be refunded. The Policy will be void from the beginning. It will be as if no Policy was issued. 3. THIS IS A LIMITED, ACCIDENT ONLY POLICY. Benefits are provided for loss due to a covered Injury up to the Maximum Benefit for each Injury. 4. STUDENT TRANSFER: An Insured may transfer to any school and still be covered, subject to the Policy provisions, exclusions and limitations. 5. INITIAL ENROLLMENT: Coverage is effective on the later of: 1) the Policy Effective Date; or 2) 12:01 a.m. on the day after premium and an application are received in the home office of the Company. 6. NO LATE ENROLLMENT: An individual may enroll anytime during the school year. Coverage is renewable annually. 7. YOUR RECEIPT OF PAYMENT is your cancelled check, credit card billing, or money order stub. Details of these benefits may be found in the Master Policy on file at the School District. NOTE: This is a brief summary of the benefits and not a

contract. A Master Policy has been provided to your school district that contains all of the provisions, limitations and exclusions and qualifications of the insurance benefits. The Master policy is the contract and will govern and control the payment of benefits. Coverage underwritten by: Starr Indemnity & Liability, Dallas, TX

LMAHHSR001 1/2015

2016OLEF20160325.STARR

ENROLL ONLINE NOW at www.K12StudentInsurance.com HSR K-12 STUDENT INSURANCE PLANS

HSR’s Student insurance products help protect kids from the bumps & bruises of growing up.

1. Browse the available Rates.

2. Pick your State -see if your School is available.

3. Open New Account - Once you have determined your school is covered, you'll need to open a new

account for this school year (you must create a new account each school year).

You have created your account for this year. Please remember your User ID and Password.

4. Add Student & Coverage by clicking on the “Add Student” button on top of page.

Continue to add each student by clicking on the “Add Student” button until all your students are added.

5. Select “Checkout”.

6. Select your payment type and click “Continue Checkout”.

7. Enter billing information and click “Continue Checkout”.

8. Click “Pay and View Receipt” to complete your order.

9. Save your receipt for future reference.

K12 Accident Plans available through your school include:

At-School Accident Only, 24-Hour Accident Only, Extended Dental & Football.

If you have questions, please call us at 1-866-409-5733.

Accident coverage underwritten by Starr Indemnity & Liability Companies, Inc, New York, NY

How to Enroll Enrolling online is easy & takes only a few minutes. Go to www.K12StudentInsurance.com

TEXAS2016-­2017

Cobertura de seguro estudiantil voluntario contra accidentes de inicial a 12º grado

Policy Form AH-20001

Cobertura asegurada por: Starr Indemnity & Liability, Dallas, TX

Elegibilidad

Todos los alumnos matriculados de una escuela/distrito participante en los grados Pre K-­12 (educación elemental y media superior).

Cobertura Opción A: 24 horas sin incluir fútbol escolar: La cobertura se encuentra disponible en todo momento excepto durante su

participación en cualquier actividad, que incluya pruebas, prácticas o cualquier concurso o juego de fútbol escolar.

Opción B: La escuela más atletismo y actividades interescolares, sin incluir fútbol escolar: Se proporciona cobertura durante 1. la

enseñanza en clase programada de forma periódica;; 2. el receso u hora del almuerzo supervisado y programado de forma

periódica;; 3. un período de estudio o de enseñanza especial supervisado por un miembro de la plana docente de la escuela;;

4. una actividad supervisada y patrocinada por la escuela;; o 5. viajes escolares cubiertos. La cobertura también se proporciona

durante deportes y actividades interescolares patrocinados por la escuela. El fútbol escolar no está cubierto.

Opción C: Solo fútbol escolar: Se proporciona cobertura durante: 1. prácticas o capacitaciones programadas de forma periódica;;

2. un concurso o juego amistoso programado de forma periódica;; 3. una prueba, sesión de entrenamiento o reuniones de

equipos programadas;; 4. una actividad cubierta de deportes patrocinados;; o 5. viajes deportivos cubiertos.

Beneficios Gastos médicos por accidente: Si la lesión cubierta de un Asegurado necesita tratamiento por parte de un médico o cirujano dentro de los 60

días siguientes a la fecha del accidente cubierto;; nosotros pagaremos los beneficios, que excedan el deducible, si los hubiere. Los gastos

médicos elegibles deben ser incurridos por el Asegurado dentro de las 52 semanas desde la fecha del accidente cubierto, están cubiertos. Los

beneficios de cualquier accidente no excederán el máximo de gastos médicos accidentales de $25.000.

Los gastos médicos elegibles incluyen • Alojamiento y comida en una habitación semiprivada;;

• Servicios hospitalarios diversos;;

• Servicios médicos, cirugía, cirujano asistente, centros quirúrgicos del médico, segunda opinión o consulta, anestesia y su administración,

visitas médicas en el hospital, visitas médicas particulares;;

• Sala de emergencias;;

• Servicios ambulatorios;;

• Radiografía, tomografía computarizada ambulatoria, resonancia magnética y pruebas de laboratorio incluyen cargos para su lectura;;

• Fisioterapia ambulatoria;;

• Aparatos ortopédicos

• Servicios de ambulancia: un viaje al hospital más cercano por aire o tierra;;

• Servicios dentales proporcionados por un dentista o médico;;

• Medicamentos recetados ambulatorios;;

• Lentes, lentes de contacto y audífonos;;

• Alquiler de equipo médico o si es menor a la compra del equipo;;

• Hernia;

Gastos médicos excesivos totales;; La empresa pagará los gastos cubiertos solo si exceden los montos a pagar por cualquier otro seguro se

haya o no solicitado los beneficios que proporciona. Otro seguro significa cualquier reembolso o recuperación de cualquier elemento de la lesión

cubierta como consecuencia de un accidente disponible de cualquier otra fuente, salvo regalos y donaciones, pero que incluyen sin limitaciones:

• Cualquier persona, grupo, póliza general o de franquicia contra accidentes, discapacidad, seguro de salud o cualquier tipo similar de acuerdo que

proporcione pagos o reembolsos de gastos médicos o pagos por discapacidad;;

• Los beneficios por discapacidad del Seguro Social;; y cualquier beneficio pagadero en virtud de cualquier programa proporcionado o patrocinado exclusiva o principalmente por unidades, agencias o subdivisionesgubernamentales, federales, estatales o locales, o por medio de la aplicación de la ley o regulación;;

salvo el Medicaid si el Titular de la póliza proporciona cobertura obligatoria para los estudiantes en virtud de otro programa, se pagarán los beneficios en virtud de esos programas antes de ser considerados bajo la póliza voluntaria.

Gasto diferido por tratamiento dental (disponible solo al elegirlo): Los gastos dentales diferidos son gastos cubiertos por tratamiento, incluyendo

radiografías para reparar las lesiones del diente (1), sin rellenos o cavidades o solo rellenos o cavidades que no debiliten las cúspides de los

dientes;; y (2) para los tejidos pulpares sanos e intactos;; y (3) para el tejido periodontal que muestre poco o ningún signo de inflamación activa

o crónica;; o para las estructuras de soporte de los dientes del Asegurado. Si hay más de una manera de tratar un problema dental, la empresa

pagará en base al procedimiento menos costoso si ese procedimiento cumple con las normas frecuentemente aceptadas de la Asociación Dental

Americana. No se proporciona cobertura para ortodoncia por ningún motivo, daño o pérdida de los mismos.

Las radiografías dentales, endodoncia y cirugía oral están cubiertas hasta $10,000 por lesión cubierta Los puentes, dentaduras postizas o

sustitución de las reparaciones dentales están cubiertos hasta $250 por lesión cubierta.

El período de beneficio para este beneficio es 52 semanas.

Muerte accidental, desmembramiento o pérdida de la visión, el habla o la audición: Pagaremos los montos de los beneficios mostrados por muerte

accidental, desmembramiento o pérdida de la visión, el habla o la audición que resulte exclusivamente de una lesión al Asegurado sufrida durante

una actividad cubierta, y de ninguna otra causa contribuyente, y se mantenga dentro de los 180 días después de la fecha de la lesión. Si un

Asegurado sufre más de una pérdida como resultado de un accidente cubierto, pagaremos solo una cantidad, la más costosa a la que él o ella

tenga derecho. Este monto no excederá la suma principal que se aplica al Asegurado.

Fallecimiento

Pérdida de dos o más manos o pies

Pérdida de la visión en ambos ojos

$10,000

$10,000

$10,000

Pérdida del habla y audición (en ambos oídos)

Pérdida de una mano o pie y visión en un ojo

Pérdida de una mano o pie

Pérdida de la visión en un ojo

$10,000

$10,000

$5,000

$5,000

Pérdida del habla

Pérdida de la audición (en ambos oídos)

Pérdida del dedo pulgar e índice de la misma mano

$5,000

$5,000

$500

Definiciones

Accidente garantizado significa un evento repentino, inesperado, específico y súbito que resulta directa e independientemente de todas las demás

causas, en una lesión cubierta o fallecimiento cubierto y cumple con todas las siguientes condiciones: 1. sucede mientras la cobertura del

Asegurado en virtud de la Póliza está vigente;; 2. sucede mientras el Asegurado asiste, participa o viaja hacia y desde una actividad cubierta;; y

3. no se excluye de otro modo en virtud de los términos de la Póliza.

Fallecimiento cubierto significa muerte accidental: 1. que es la consecuencia directa de un accidente cubierto;; 2. que resulta directa e

independientemente de todas las demás causas de un accidente cubierto e independiente de la enfermedad, incapacidad mental, enfermedad

corporal o cualquier otra causa;; y 3. sufrido por el Asegurado dentro del período de tiempo aplicable especificado en el programa de beneficios.

Lesión cubierta significa lesión corporal accidental: 1. que sufre un Asegurado como consecuencia directa de un accidente cubierto externo al

cuerpo;; 2. que resulta directa e independientemente de todas las demás causas de un accidente cubierto (independiente de la enfermedad,

incapacidad mental, enfermedad corporal o cualquier otra causa) que cause una pérdida cubierta;; y 3. sufrido por el Asegurado dentro del

período de tiempo aplicable especificado en el programa de beneficios. La lesión cubierta debe ser causada por medios accidentales. Todas las

lesiones sufridas por un Asegurado en cualquier accidente, incluyendo las condiciones relacionadas y síntomas recurrentes de estas lesiones, se

consideran una sola lesión.

Pérdida cubierta significa una pérdida que resulta de una lesión o muerte cubierta, y para los cuales se pagan beneficios en virtud de la Póliza.

Pérdida cubierta incluye los gastos derivados de los servicios o suministros prestados u obtenidos por el Asegurado si tales servicios y

suministros están cubiertos por la Póliza.

Pérdida de una mano o pie significa la separación completa a través o por encima de la muñeca o el tobillo. Pérdida de la audición significa la pérdida total y permanente de la capacidad de escuchar cualquier sonido en ambos oídos, la cual no se puede recuperar por medios naturales, quirúrgicos o artificiales. Pérdida de la visión significa la pérdida total y permanente de la visión de un ojo. La pérdida de la visión no se puede recuperar por medios naturales, quirúrgicos o artificiales. Pérdida del habla significa la pérdida total y permanente de la comunicación acústica, la cual no se puede recuperar por medios naturales, quirúrgicos o artificiales. Pérdida de un dedo pulgar e índice de la misma mano significa la separación completa a través o por encima de la articulación metacarpofalángica de la misma mano (las articulaciones entre los dedos y la mano).

Exclusiones y limitaciones Esta Póliza no cubre:

1. Lesiones intencionales o autoinfligidas, suicidio o cualquier intento esté en su sano juicio o no;; 2. Tentativa o intento de cometer un delito

grave o asalto;; 3. Tentativa o participación activa en una huelga o insurrección;; 4. Guerra o acto de guerra declarado o no o cualquier acto de

guerra declarado o no a menos que sean previstos de manera específica por la Póliza;; 5. Intoxicación del Asegurado, según se determina de

conformidad con las leyes de la jurisdicción en la que se produjo la pérdida cubierta o las leyes del país de origen;; 6. Ingestión voluntaria de

cualquier narcótico, medicamento, veneno, gas o vapor, a menos que sean recetados o tomados bajo la instrucción de un médico y tomados de

acuerdo con la dosis recetada;; 7. Una pérdida cubierta que ocurre mientras está en servicio militar, naval o aéreo activo de cualquier país u

organización internacional. Una vez recibida la prueba de servicio de la empresa, ésta reembolsará cualquier prima pagada por este tiempo. La

formación en servicio activo de la Guardia Nacional o Reserva está incluida a no ser que se extienda más allá de los 31 días;; 8. Viaje o

actividad fuera de los Estados Unidos;; 9. Vuelo, embarque o salida de una aeronave o de cualquier nave diseñada para volar sobre la superficie

de la Tierra, salvo que: a. Un pasajero que paga la tarifa en una aerolínea comercial programada regularmente;; b. Un pasajero en un nave

privada no programada usada por placer sin intención comercial durante el vuelo;; c. Un pasajero en un avión militar volado por el Comando de

Movilidad Aérea o su equivalente en el extranjero;; 10. Puenting;; salto en caída libre;; paracaidismo;; paracaidismo náutico;; ala delta;; esquí;;

submarinismo;; surf;; patinaje sobre ruedas;; rodeo a ganado mayor;; vuelo en planeador;; vuelo en un avión ultraligero;; sailplaning ;; trineo o

tobogán;; viaje en globo;; peleas o enfrentamientos excepto en defensa propia;; hacer funcionar, sentarse o montar en o sobre, posarse en o

desde, o trabajar en o alrededor de cualquier motocicleta o vehículo de recreo, que incluye pero no limita vehículos de dos o tres ruedas,

cuatrimotos todo terreno (ATV), motos acuáticas, bicicletas de esquí, motos de nieve;; 11. Enfermedad, debilidad física o mental, infección

bacteriana o viral o tratamiento médico o quirúrgico de las mismas, excepto por cualquier infección bacteriana que resulte de un corte o una

herida externa accidental o ingestión accidental de alimentos contaminados;;12. Viajar en o sobre cualquier vehículo todoterreno motorizado que no

requiera licencia como vehículo automotor;;13. Lesiones compensables en virtud de la Ley de indemnización de trabajadores o cualquier ley similar;;

14. Un accidente si el Asegurado es el conductor de un vehículo y no posee una licencia de conducir válida, a menos que: (a) el Asegurado

tenga un permiso de aprendiz válido y (b) el Asegurado esté recibiendo clases de manejo por parte de un instructor de educación vial;; Asimismo,

los beneficios no se pagarán por los servicios o tratamientos recibidos por cualquier persona que sea: Empleada o contratada por el Titular de la

póliza;; Un residente de la misma casa;; Un miembro de la familia inmediata, incluso la pareja de hecho del Asegurado o el cónyuge del

Asegurado;; el Asegurado.

Seguro estudiantil voluntario contra accidentes en Texas - Programa de beneficios

BENEFICIO DE GASTOS MÉDICOS POR

ACCIDENTE ECONÓMICO PREMIER

Beneficio máximo de gastos por accidente

excesivo total $25,000 $25,000

Los primeros gastos cubiertos deben ser

recibidos dentro de 60 días después de la lesión cubierta 60 días después de la lesión cubierta

Período del beneficio 1 año desde la fecha de la lesión cubierta 1 año desde la fecha de la lesión cubierta

Límite del beneficio para lesiones cubiertas

derivadas de cualquier accidente automovilístico $5,000 $5,000

SERVICIOS DE HOSPITALIZACIÓN

Gastos de alojamiento y comida

Habitación semiprivada 100 % de los cargos habituales y acostumbrados 100 % de los cargos habituales y acostumbrados

Gastos hospitalarios diversos hasta $250 por día, hasta un máximo de $4,000 por

lesión cubierta hasta $250 por día, hasta un máximo de $5,000

por lesión cubierta

Tratamiento en la sala de emergencias hasta $75 por lesión cubierta hasta $150 por lesión cubierta

El tratamiento en la sala de emergencias debe

ocurrir dentro de 72 horas de la lesión cubierta 72 horas de la lesión cubierta

Servicios de enfermería hasta $400 por lesión cubierta hasta $400 por lesión cubierta

Servicios médicos

Cirugía 75 % de los cargos habituales y acostumbrados hasta

$3,500 por lesión cubierta 75 % de los cargos habituales y acostumbrados

hasta $3,750 por lesión cubierta

Cirujano asistente 25 % de los gastos incurridos en la cirugía realizada

por el médico 25 % de los gastos incurridos en la cirugía

realizada por el médico

Anestesia y su administración 25 % de los gastos incurridos en la cirugía realizada

por el médico 25 % de los gastos incurridos en la cirugía

realizada por el médico

Visitas médicas no quirúrgicas dentro del hospital hasta $20 por visita hasta $40 por visita

BENEFICIOS AMBULATORIOS

Visitas médicas no quirúrgicas particulares hasta $20 por visita hasta $40 por visita

Máximo combinado por tomografía

computarizada, resonancia magnética hasta $250 por lesión cubierta hasta $500 por lesión cubierta

Radiografía hasta $100 por lesión cubierta hasta $200 por lesión cubierta

Pruebas de laboratorio hasta $50 por lesión cubierta hasta $100 por lesión cubierta

Beneficio de fisioterapia ambulatoria hasta 2 tratamientos;; hasta $40 por lesión cubierta;;

1 visita al día hasta 5 tratamientos;; hasta $100 por lesión

cubierta;; 1 visita al día

Aparatos ortopédicos ambulatorios hasta $300 por lesión cubierta hasta $300 por lesión cubierta

Pago hospitalario a establecimientos para cirugía

ambulatoria hasta $750 por lesión cubierta hasta $1,250 por lesión cubierta

Servicios de ambulancia hasta $100 por año de Póliza 100 % de los cargos habituales y acostumbrados

Equipo médico hasta $150 por lesión cubierta hasta $150 por lesión cubierta

Servicios dentales hasta $150 por diente hasta $250 por diente

Medicamentos recetados ambulatorios 100 % de los cargos habituales y acostumbrados 100 % de los cargos habituales y acostumbrados

Lentes, lentes de contacto, audífonos 100 % de los cargos habituales y acostumbrados 100 % de los cargos habituales y acostumbrados

DISPONIBLE SOLO AL ELEGIRLO

Tratamiento diferido -­ dental

hasta $10,000 por lesión cubierta El costo de los

puentes, dentaduras postizas o sustitución de las

reparaciones dentales están cubiertos hasta $250 por

lesión cubierta;; periodo de beneficio de 52 semanas

hasta $10,000 por lesión cubierta El costo de los

puentes, dentaduras postizas o sustitución de las

reparaciones dentales están cubiertos hasta $250

por lesión cubierta;; periodo de beneficio de 52

semanas

Opciones de precios y plan

sin tratamiento dental diferido con tratamiento dental diferido

Económico Premier Económico Premier

Opción A, 24 horas sin fútbol escolar $109.00 $ 167.00 $117.00 $175.00

Opción B, en la escuela sin fútbol escolar $ 54.00 $ 80.00 $ 62.00 $88.00

Opción C, Fútbol escolar $161.00 $ 247.00 $169.00 $255.00

Opción C, Fútbol escolar de primavera $ 65.00 $ 99.00 $ 73.00 $107.00

Nota: Cualquier estudiante de 9º grado que juegue con el equipo de fútbol escolar (10º a 12º grado) debe adquirir una cobertura de fútbol.

2016-­2017

SEGURO ESTUDIANTIL VOLUNTARIO CONTRA ACCIDENTES

FORMULARIO DE INSCRIPCIÓN_______________________ ______________________

Apellido del estudiante Fecha de nacimiento del estudiante

(MM-­DD-­AAAA)

_______________________________ _____ ______________________________

Nombre del estudiante MI Teléfono

_______________________________ ____________ ______________________________

Número del seguro social del estudiante Grado Número de identificación del estudiante

______________ _________________________________________________________________

Calle no. Dirección

______________________________ ____________________________ ___________

Ciudad Estado Código postal

______________________________ ____________________________________________

Nombre del distrito escolar Nombre de la escuela/campus (necesario para el proceso)

____________________________________________ __________________________

Firma del padre/tutor Fecha

___________________________________________

Correo electrónico

Sírvase elegir su plan a continuación:

Sin tratamiento dental diferido Con tratamiento dental diferido

Económico* Premier* Económico* Premier*

Opción A 24 horas sin fútbol escolar $109.00 $167.00 $117.00 $175.00

Opción B en la escuela sin fútbol escolar $54.00 $80.00 $62.00 $88.00

Opción C Fútbol escolar $161.00 $247.00 $169.00 $255.00

Opción C Fútbol escolar de primavera $65.00 $99.00 $73.00 $107.00

SOLO para uso interno:

Cheque no.:_________________________

Cant. reg.: __________________________

Adjunte el cheque por el importe total a pagar a: Health Special Risk

TOTAL Todas las elecciones AQUÍ: _______________________________

*Hay una cuota administrativa de $1,00 por cada envío del formulario de inscripción impreso.

Una vez completado, envíe este formulario a:

Health Special Risk, Inc. Apartado postal 674239 Dallas, TX 75267-­4239

Para obtener más información o ayuda con respecto a todos los seguros estudiantiles, póngase en contacto con nuestro Departamento de Servicio

al Cliente al 866-­243-­7885.

SI DESEA PAGAR CON MASTERCARD O VISA**: Visite www.K12StudentInsurance.com ** Se añadirá un cargo administrativo del 5% por los pedidos con tarjetas de crédito

INFORMACIÓN SOBRE LA PÓLIZA 1. LAS PÓLIZAS TIENEN UN PERIODO RENOVABLE DE UN AÑO. 2. DERECHO DE 30 DÍAS PARA EXAMINAR LA PÓLIZA: Si no está satisfecho con esta

Póliza, por cualquier motivo, devuélvalo dentro de 30 días después de recibirlo. Cualquier prima pagada será reembolsada. La Póliza será nula desde el principio. Será como si no se hubiera

emitido la Póliza. 3. LA PRESENTE ES UNA PÓLIZA LIMITADA SOLO CONTRA ACCIDENTES Se proporcionan beneficios por pérdida a causa de una lesión cubierta hasta el beneficio máximo

por cada lesión. 4. TRANSFERENCIA DEL ESTUDIANTE: Un Asegurado puede ser transferido a cualquier escuela y aún tener cobertura, sujeto a las disposiciones, exclusiones y limitaciones de la

Póliza. 5. INSCRIPCIÓN INICIAL: La cobertura es vigente después de: 1) la fecha de vigencia de la Póliza;; o 2) 12:01a.m. del día siguiente que se reciba la prima y la solicitud en la oficina

central de la empresa. 6. SIN INSCRIPCIÓN TARDÍA: Una persona puede inscribirse en cualquier momento durante el año escolar. La cobertura se renueva cada año. 7. SU RECIBO DE PAGO

es su talón de cheques, facturación de tarjetas de crédito o giro postal cancelado. Puede encontrar la información sobre estos beneficios en la Póliza maestra de los archivos del distrito escolar.

NOTA: Este es un breve resumen de los beneficios y no un contrato. Al distrito escolar se le ha proporcionado una Póliza maestra, que contiene todas las disposiciones, limitaciones, exclusiones y calificaciones de los beneficios del seguro. La Póliza maestral es el contrato y regulará y controlará el pago de los beneficios. Cobertura asegurada por: Starr Indemnity & Liability, Dallas, TX

LMAHHSR001 1/2015

2016OLEF20160325.STARR

Inscribase ahora en www.K12Student Insurance.com HSR K-12 PLANES DE COBERTURA DE SEGURO PARA ESTUDIANTES

El producto de HSR Cobertura de Seguro para Estudiantes, ayuda a proteger a miles de niños/niñas de los golpes y moretones del crecer.

COMO INSCRIBIRSE Inscribirse en linea, es tan censillo, y solamente toma unos minutos.

Por favor entre a la pagina www.k12studentinsurance.com

1. Revise las tarifas disponibles.

2. Elija su Estado y confirme que su escuela este disponible por el año escolar en curso

3. Abrir una Nueva Cuenta- Una vez que haya verificado que su escuela ofrece cobertura, devera abrir una nueva

cuenta para el año escolar en curso. (Devera crear una nueva cuenta cada año escolar). Ha creado su cuenta para el

año en curso…recuerde su identificacion de usuario y la contraseña.

4. Agregue el nombre del estudiante y la cobertura, oprimiendo el boton “add student” al final de la pagina.

Continue agregando los nombres por cada estudiante, hasta terminar con todos los nombres necesarios.

5. Seleccione el boton de “checkout”

6. .Seleccione su forma de pago oprimiendo el boton “continue checkout” al final de la pagina para continuar con el

pago

7. Llene la dirección a donde recive su correspondencia y oprima el boton “continue checkout” al finial de la

pagina.

8. Para continuar con su orden, oprima el boton “Pay and View Receipt”.

9. Guarde su recivo como referencia, por si lo necesita en el futuro.

Los planes de polizas K12 en caso de accidente o enfermedad, disponibles por su escuela incluyen: 24 horas

solamente en caso de accidente; Extencion de plan dental y accidente durante el deporte de Football Americano.

Si tiene preguntas por favor llámenos al: 1 866 409 5733.

Cobertura de accidente suscrita por Starr Indemnity & Liability Companies, Inc, New York, NY

Frequently Asked Questions

Basic Coverage:

Is the District required to carry insurance on students for accidental injuries or while

participating in UIL activities?

School Districts are not required to carry insurance on students.

What does the Blanket Insurance cover? Blanket Insurance covers all University Interscholastic League (UIL) Athletics and Activities,

including, but not limited to interscholastic football, basketball, baseball cheerleading, drill team,

soccer vocational classes, band, orchestra, choir, one-act plays, etc. It is provided during the

hours and days when school is in session and while attending or participating in school

sponsored and supervised activities on or off school premises. Coverage is provided while

traveling to, during or after such activities as a member of a group in transportation furnished

or arranged by the Policyholder and traveling directly to or from the Insured’s home

premises and school premises when school is in session. For a list of all covered UIL

activities, please visit the following site:

http://www.uil.utexas.edu/policy/constitution/index.html (Section 380).

Includes Day Field Trips PK-12 (up to $25,000 medical).

What grades are covered under the blanket plan? The Blanket plan covers grades 7-12.

Is the UIL insurance primary or secondary coverage? The UIL insurance is secondary unless there is no other coverage. Then it becomes primary. (It is,

however primary to CHIP, Military, Medicaid, and other government insurance.)

What is the deductible for the blanket insurance? There is no deductible.

When does the blanket coverage become effective?

Coverage is effective on August 1st

through July 31st

.

How soon must medical treatment occur after an accident for coverage to be effective?

Medical treatment must be sought within 90 days from the date of injury.

How long after an accident can medical treatment still be covered? Medical treatment will be covered up to 52 weeks after the initial date of injury.

Who is responsible for filing the student insurance claims? The parents or legal guardians of the injured student are responsible for filing all claims. We

do recommend that coaches or trainers keep copies, however. Coaches and Trainers are NOT

responsible, but often take on this responsibility to help parents. Call us anytime you need help.

How long do parents have to file a claim? Parents have 90 days from the date of injury to file a claim.

Are there any exclusions in the blanket coverage? Yes, there are exclusions to the blanket coverage. Please read the Exclusions and Definition

clauses of the policy.

What do we do if parents DO have insurance? If parents have insurance, their insurance is primary. However, they should file a claim with

their insurance and the student insurance at the same time. When they receive itemized bills

and EOBs (Explanation of Benefits), they need to send those into the student insurance.

What do we do if parents DO NOT have insurance?

Parents still need to file a claim with our insurance. Our insurance will become Primary if they don’t

have any insurance.

If parents do not have other insurance, we recommend that they use a doctor/provider in Network. If

you use the Texas Student Resources and Health Risk (HSR) Network, providers have agreed to

accept plan benefits as payment in full with no balance billing to parents.

Voluntary Coverage:

What does the Voluntary Insurance Cover? All Voluntary Insurance Plans cover accidents only. Accidents covered depend on the type of

plan purchased. Option A - 24-Hour Coverage excluding High School Football or Option B

- School plus Interscholastic Athletics & Activities excluding High School Football or Option

C - High School Football only:

What is the deductible for the Voluntary insurance? The Voluntary accident insurance has no deductible.

Is there a cut off period for enrollment? No, parents can purchase these plans anytime during the school year.

How soon must medical treatment occur after an accident for coverage to be effective?

Medical treatment must be sought within 90 days from the date of injury.

How long after an accident can medical treatment still be covered? Medical treatment will be covered up to 52 weeks after the initial date of injury.

How long do parents have to file a claim? Parents have 90 days from the date of injury to file a claim.

.

K12 Claim Form 2014-11-13

Listed below are important instructions and comments about filing a claim.

YOUR CLAIM FORM

1. This claim form should be fully completed and submitted within 90 days from the date ofinjury. Be sure to answer and complete the section regarding “OTHER INSURANCESTATEMENT”, marking either yes or no, and signing the line for authorization, so thatHSR and the doctors/hospital may communicate concerning your claim.Incomplete claim forms are one of the most frequent reasons why claim payments aredelayed.

2. Only one claim form for each accident needs to be submitted.3. Once completed, make a photocopy for your records, and mail to the address shown below.4. DO NOT assume that anyone else will mail this claim form to HSR for you.

YOUR BILLS

1. Please advise all doctors/hospitals regarding this coverage so they may forward us theiritemized bills.

2. If you have already been to the doctor/hospital and did not know about this coverage, thenplease send all of the itemized bills to HSR at the address shown below.

3. The bills should include the name of the doctor/hospital, their complete mailing address,telephone number, the date you were seen by the doctor/hospital, what the doctor saw you for(diagnosis) and the specific itemized charges (description of treatment and amount) incurred(including the CPT/procedure code).

4. If this information is not on the bill when you send this in we will have to contact thedoctor/hospital which will delay the review of your claim. “Balance Due” or “BalanceForward” statements do not contain sufficient information to complete your claim.

EXCESS INSURANCE

1. This policy provides coverage on a secondary/excess basis. If you have any other primaryinsurance coverage you need to send the bills to your primary insurance first.

2. HSR will consider benefits after your other, primary insurance has processed the claim.3. We will require a copy of your primary insurance Explanation of Benefits (EOB) which you

should receive from your primary insurance letting you know what was paid or denied, andthe reason(s) why.

4. HSR will not be able to consider your claim without this information.

If you have any questions, please contact Customer Service at (866) 409-5734. They are available from 8:00 a.m. thru 6:00 p.m. central time, Monday – Friday. You may also forward any documents by fax to (972) 512-5818.

Health Special Risk, Inc. P.O. Box 117558

Carrollton, TX 75011-7558

PART I – POLICYHOLDER’S REPORT1. Claimant’s Name (injured/ill person) 2. Social Security Number 3. Gender

M F 4. Date of Birth 5. E-Mail

6. Address of Injured Person 7. Phone Number (include area code)

8. Parent/Legal Guardian Name, Address, City, State & Zip 9. Phone Number (include area code)

10. Date of Accident/Illness 11. Time of Accident a.m. p.m.

12. Place where Accident Occurred 13. Date of First Treatment

Dental Claims

14. Indicate which Teeth were Involved in the Accident 15. Describe Condition of Injured Teeth Prior to Accident: Whole, Sound, and Natural Filled Capped Artificial

16. Type of Injury (Indicate Part of Body Injured – e.g. broken arm, sprained ankle, etc.) Did Injury Result in Death? Yes No

17. Describe How Accident Occurred or the Nature of the Illness – Give all possible details

18. Which Best Describes the Activity:Play or practice of interscholastic sports Not school relatedP.E. class

During lunch hour In school bus School sponsored field trip Traveling to/from school

Athletic period On school property during school hours School sponsored activity during school hours ROTC activity

19. Name of Person Supervising the Activity 20. If engaged in an Interscholastic Sport at the time of the injury, what was the sport?

Signature of Parent/Legal Guardian: X Date:

Signature of School Official: X Date:

PART II – OTHER INSURANCE STATEMENTDo you/spouse/parent have medical/health care or is the Claimant enrolled as an individual, employee or dependent member of a Health Maintenance Organization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through your employer or other source on you or, if applicable, does your son/daughter have health care coverage as a dependent from your previous marriage as mandated in a divorce decree? Yes No

If Yes, name of insurance company Policy #

Name of insurance company Policy #

If applicable, claimant’s primary employer name, address, and phone number

If applicable, mother’s primary employer name, address, and phone number

If applicable, father’s primary employer name, address, and phone number

IF OTHER INSURANCE OR HEALTH CARE PLANS EXIST, PLEASE SUBMIT COPIES of their EXPLANATION OF BENEFITS along with your claim. IF NO OTHER INSURANCE or HEALTH PLAN EXISTS, PLEASE READ & SIGN BELOW. I agree that should it be determined at a later date there is insurance (or similar), to reimburse HEALTH SPECIAL RISK, INC., or the insurance company to the extent of any amount collectible. Signature of Parent/Legal Guardian: X Date:

Signature of Witness: X Date:

PART III – AUTHORIZATION TO PAY BENEFITS TO PROVIDER I hereby authorize medical payments to be made directly to doctor(s), hospital(s), or indicated provider(s) of service(s) in connection with this claim. (If not signed submit proof of payment)

SIGNATURE _____________________________________________________________________________________________________ DATE ____________________________

I hereby authorize any insurance company, hospital, physician or other person who has attended or examined the claimant to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A photo static copy of this authorization shall be considered as effective and valid as the original.

SIGNATURE DATE

By entering your name above in Part II and Part III, you are signing this claim form electronically. You agree yourelectronic signature is the legal equivalent of your manual/handwritten signature on this claim form.

P.O. Box 117558 Carrollton, Texas 75011-7558

Phone: (972) 512-5600 Fax: (972) 512-5818 Toll Free (866) 409-5734

E-mail : K12claims@hsri.com

1. Please fully complete this form2. Attach itemized bills3. Mail, E-mail or Fax to HSR

STUDENT CLAIM FORM

School District:

School Name:

Student ID Number:

K12 Claim Form Fill-able 2015-10-19

FRAUD STATEMENTS

FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Alaska and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Maryland, West Virginia &Rhode Island: Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony. Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: WARNING :Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Georgia: Any natural person who knowingly or willfully 1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing:

a) In any written statement; b) In the filing of a claim; or c) In the receiving of money for an application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or

fraudulent claim or other benefit by an insurer; 2) Receives money for the purpose of purchasing insurance and converts such money to such persons own benefit; 3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or 4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement for the purpose of fraudulently

obtaining money or benefit from an insurer commits the crime of insurance fraud. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects the person to criminal and civil penalties. Minnesota; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under state or federal law, or both, and may be subject to civil penalties. New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Warning: Any person who knowingly, and with intent to defraud any insurance company or other persons files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, may be subject to prosecution for insurance fraud. Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

K12 Claim Form Fill-able 2015-10-19