OPTIONAL SCHOOL TIME ACCIDENT COVERAGE
|Annual Premium:||Plan “Basic”||Plan “A”||Plan “B”||Plan “C”|
|Excluding all Senior High Sports||$9.00||$12.00||$29.00||$45.00|
|Including all Sports Except Senior High Football||$24.00||$27.00||N/A||N/A|
Insurance coverage is provided for covered Injuries incurred 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.
Includes participation in:
- Interscholastic Sports (if premium paid for), excluding Senior High (participating with grades 10-12) interscholastic tackle football
- Summer Recreation Activities sponsored by the school
- One-Day School Field Trips (excludes trips of 7 or more consecutive nights) and School Sponsored Religious Activities.
Coverage is provided for 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 their home premises and the school or the site of a covered activity.
OPTIONAL 24-HOUR ACCIDENT COVERAGE
|Annual Premium:||Plan “Basic”||Plan “A”||Plan “B”||Plan “C”|
|Excluding all Senior High Sports||$65.00||$77.00||$150.00||$225.00|
|Including all Sports Except Senior High Football||$80.00||$92.0||N/A||N/A|
Insurance coverage is provided around the clock, 24 Hours per day. Provides coverage during the weekends and vacation periods including the entire summer. Students are protected while at Home or away, any place, any time, anywhere. Coverage is provided for participation in Interscholastic Sports (if premium paid for), excluding Senior High (participating with grades 10-12) interscholastic tackle football.
OPTIONAL FOOTBALL COVERAGE
|Annual Premium:||Plan “Basic”||Plan “A”||Plan “B”||Plan “C”|
|Fall and Spring/Summer||$75.00||$110.00||N/A||N/A|
(for new players who participate in spring/summer and not already insured under the Fall and Spring/Summer option)
Covers Accidents occurring while participating in high school interscholastic tackle football practice or competition. Travel is covered when going directly and uninterruptedly to or from such practice or competition as part of a group in transportation furnished or arranged by the Policyholder. Refer to benefits and limitations described inside this brochure.
Optional Football Coverage begins on the date of premium receipt and ends on the last day of practice or competition. Ninth Graders who play with 9th graders ONLY are not charged extra for football coverage. Their Optional School-Time or Optional 24-Hour Accident Coverage will apply if purchased.
OPTIONAL 24-HOUR DENTAL COVERAGE
Can be purchased separately or with other coverage. Insurance coverage is in effect 24 Hours a day. Injury must be treated within 60 days after the Accident occurs. Benefits are payable within 12 months after the date of Injury. The maximum eligible expenses payable per covered Injury is $25,000.
In addition, when the dentist certifies that treatment must be deferred until after the Benefit Period, deferred benefits will be paid to a maximum of $1,000. The Student must be treated by a legally qualified dentist who is not a member of the student’s Immediate Family for Injury to teeth. Coverage is limited to treatment of sound, natural teeth.
Coverage under the Optional School-Time Accident Coverage, the Optional 24-Hour Accident Coverage and the Optional 24-Hour Dental Coverage starts on the date of premium receipt but not before the start of the school year. Optional School-Time Accident Coverage ends at the close of the regular nine-month school term, except while the student is attending academic classroom sessions exclusively sponsored and solely supervised by the School during the summer. Optional 24-Hour Accident and Dental Coverage ends when school reopens for the following school year. Coverage is available under the plan throughout the school year at the premiums quoted (no pro rata premiums available).
EXCESS COVERAGE PROVISION
The Company will pay Reasonable Expenses that are not recoverable from any Other Plan. The Company will determine the amount of benefits provided by Other Plans without reference to any coordination of benefits, non-duplication of benefits, or similar provisions. The amount from Other Plans includes any amount, to which the Insured is entitled, whether or not a claim is made for the benefits. This Blanket Student Accident Insurance is secondary to all other policies. This provision will not apply if the total Reasonable Expenses incurred for Hospital and Professional Services Benefits are less than the amount stated in the Schedule of Benefits under Excess Coverage Applicability.
When a covered Injury to a student results in 1) treatment by a legally qualified Physician or surgeon (other than a member of the immediate family or person retained by the school) or 2) Hospital confinement, and treatment begins within 90 days from the date of Injury, the Company will pay the benefit as shown in the Schedule of Benefits, subject to the Excess Coverage Provision above. Only eligible medical expenses incurred by the Insured within 52 weeks from the date of the Accident are covered. Benefits for any one Accident shall not exceed in the aggregate the maximum stated in the Medical Benefit plan purchased. Expenses incurred after one year from the date of Injury are not covered, even though the service is a continuing one, or one that is necessarily delayed beyond one year from the date of Injury.
ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT
When a covered Injury results in any of the Losses to the Insured which are stated in the Schedule of Benefits for Accidental Death, Dismemberment, or Loss of Sight then the Company will pay the benefit stated in the schedule for that Loss. The Loss must be sustained within 365 days after the date of the Accident.
The maximum benefit payable under this provision is stated in the Schedule of Benefits under Maximums and Benefit Period:
- Both Hands or Both Feet or Sight of Both Eyes
- Loss of One Hand and One Foot
- Loss of One Hand and Entire Sight of One Eye
- Loss of One Foot and Entire Sight of One Eye
- Loss of One Hand or Foot
- Loss of Sight in One Eye
- Loss of Speech
- Loss of Hearing (both ears)
- Loss of Speech and Hearing (both ears)
- Loss of Thumb and Index Finger of the Same Hand
Half of the maximum benefit will be paid for the Loss of one Hand, one Foot or the Sight of one eye. Loss of Hand or Foot means the complete Severance through or above the wrist or ankle joint. Loss of Sight means the total, permanent Loss of Sight in 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 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 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). Severance means the complete separation and dismemberment of the part from the body. If the Insured suffers more than one of the above covered losses as a result of the same Accident the total amount the Company will pay is the maximum benefit. Benefits paid under this provision will be paid in addition to any other benefits provided by the Policy. Benefits under this provision are subject to all other provisions of the Policy, including all Coverage and Limitations, Maximums and Exclusions.
Injury means bodily injury caused by an Accident. The Injury must occur while the Policy is in force and while the Insured is covered under the Policy. The Injury must be sustained as stated on the face page of the Policy, except where specifically stated otherwise in the Policy.
Accident means a sudden, unexpected, specific and abrupt event that occurs by chance at an identifiable time and place. The Accident must occur while the Insured is covered under the Policy.
Reasonable Expense means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. Such services and supplies must be recommended and approved by a Physician.
No Benefits are payable for Hospital and Professional Services for the following:
- Injuries which are not caused by an Accident
- Treatment for hernia, regardless of cause, Osgood Schlatter’s disease, or osteochondritis
- Injury sustained as a result of operating, riding in or upon, or alighting from a two-, three-, or four-wheeled recreational motor vehicle or snowmobile
- Aggravation, during a Regularly Scheduled Activity, of an Injury the Insured suffered before participating in that Regularly Scheduled Activity, unless the Company receives a written medical release from the Insured’s Physician
- Injury sustained as a result of practice or play in interscholastic tackle football and/or sports, unless the premium required under the Football and/or Sports Coverage provision has been paid
- Any expense for which benefits are payable under a Catastrophic Accident Insurance Program of the State Interscholastic Activities Association
- Treatment performed by a member of the Insured’s Immediate Family or by a person retained by the School
- Injury caused by declared or undeclared War or acts of War; suicide, while sane or insane; violating or attempting to violate the law; the taking part in any illegal occupation; fighting or brawling except in self defense; being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs; or being under the influence of any drugs or narcotic unless administered by or on the advice of a Physician
- Medical expenses for which the Insuredreceived benefits under any (a) Workers’ Compensation act; or (b) mandatory no-fault automobile insurance contract; or similar legislation
- Expense incurred for treatment of temporomandibular joint dysfunction and associated myofacial pain
- Expenses incurred for experimental or investigational treatment or procedures.
RETAIN THIS DESCRIPTION FOR YOUR RECORDS
This is not a Policy, rather a brief description of the benefits provided under the master policy issued to the school. Please refer to the master policy for further details. IMPORTANT NOTICE – THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. This brochure has been designed to illustrate the highlights of this insurance. All information in this brochure is subject to the provisions of Policy Form COL-11-FL, underwritten by Gerber Life Insurance Company (the Company). If there is any conflict between this brochure and the Policy, the Policy will prevail. Please see the Master Policy for individual state details.
HOW TO FILE A CLAIM
Written notice of claim must be given to the Company within 90 days after the occurrence or commencement of any loss covered by this policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Named Insured to the Company, with information sufficient to identify the Named Insured shall be deemed notice to the Company. Written proof of loss must be furnished to the Company at its said office within 90 days after the date of such loss.
In the event of an Accident, students should: 1) Secure treatment at the nearest medical facility of their choice; 2) If you have other insurance, submit your claim to your other insurer. When you receive the explanation of benefits notice from your primary carrier, send it to us; 3) Obtain a receipt (if payment of any bills were made) and itemized copy of charges from the provider of medical services and send copies of their itemized bills and the fully completed and signed accident claim form to the claims office – mail all correspondence to WEB-TPA, P.O. Box 2415, Grapevine, TX 76099-2415; and 4) Call 1-866-975-9468 with any Claims questions.
|UNDERWRITTEN BY:||MARKETING AGENT:|
|Gerber Life Insurance Company||Fowinkle School Insurance Agency|
|White Plains, NY 10605||120-53rd Avenue West
Bradenton, FL 34207