STUDENT ACCIDENT INSURANCE PLAN (the Plan )

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1 STUDENT ACCIDENT INSURANCE PLAN (the Plan ) SCHOOL TIME ACCIDENT COVERAGE OR 24-HOUR ACCIDENT COVERAGE IMPORTANT NOTE: This Plan provides accident insurance only. It does not provide basic hospital, basic medical, or major medical for sickness coverage. ENROLL ONLINE at Insurance Plan Underwritten By: National Union Fire Insurance Company of Pittsburgh, Pa., with its principal place of business in New York, NY (the Company ) Claims Administrator: AIG, Educational Markets, Mail Center, P.O. Box 26008, Overland Park, KS (phone) This brochure is for use in the following states: AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MS, MO, MT, NE, NV, NJ, NM, NC, ND, OK, RI, SC, SD, TN, TX, UT, VT, VA, WV, WI and WY. *Specific provisions, definitions, exclusions and coverages applicable to the Policy issued in your state are contained in the Policy on file with the District/School. Please refer to the State Specific Variations sections of this brochure for more details. Please keep this brochure as a general summary of the insurance. This is only a brief description of the accident coverage available under policy series C11695DBG. The Policy contains additional reductions, limitations, exclusions, definitions and termination provisions. Full details of the coverage are contained in the Policy on file with the District/ School ( the Policyholder/the Participating Organization ). If there is any conflict between the contents of this brochure and the Policy, the Policy shall govern in all cases. Coverage may not be available in all states. CLAIMS PROCEDURE In the event of an accident, notify the school immediately. Secure a claim form from the District/School, attach bill(s) to completed claim form and mail to the address listed below. Claims for benefits must be filed within 90 days from date of accident, or as soon as reasonably possible. The Company must be notified of a loss within 20 days of such accident. AIG, Educational Markets Mail Center P.O. Box Overland Park, KS Phone: AS-XS

2 SCHOOL TIME ACCIDENT COVERAGE If coverage is elected and appropriate premium is received, this accident insurance provides coverage while the Insured is at school and also while the Insured is attending or participating in school sponsored and supervised activities on or off school premises (excluding senior high school interscholastic football and/or sports). Includes: Travel to and from school School sponsored summer activities Class trips 24-HOUR ACCIDENT COVERAGE If coverage is elected and appropriate premium is received, this accident insurance provides coverage 24-hours per day, including while the Insured is at school and also while the Insured is attending or participating in school sponsored and supervised activities on or off school premises (excluding senior high school interscholastic football and/or sports). Includes: Weekends Vacation periods, including summer vacation Coverage at home or while away INSURED S EFFECTIVE AND TERMINATION DATES An Insured s coverage under the Policy begins at 12:01 a.m. on the latest of: (1) the Policy effective date; (2) the date for which the first premium for the Insured s coverage is paid; (3) the date the person becomes a member of an eligible class of persons as described in the Policy; or (4) the date written enrollment is received. Coverage under the Policy ends at 12:01 a.m. on the earliest of: (1) the date the Policy is terminated; (2) the end of the period for which premiums for the Insured s coverage have been paid; (3) the date the Insured ceases to be a member of any eligible class(es) of persons as described in the Policy; or (4) the date the Insured requests, in writing, that his or her coverage be terminated. The Policy effective and termination dates are contained in the Policy on file with the District/School ( the Policyholder/the Participating Organization ). EXCESS COVERAGE* This Plan is secondary and provides benefits in accordance with all of its provisions only to the extent that benefits are not provided by any other plan providing accident medical expense benefits. If the Insured is covered by another plan providing accident medical expense benefits, all benefits payable by such other insurance will be determined before benefits will be paid by this Plan. If the Insured is not covered by another plan providing accident medical expense benefits, this excess provision shall not apply and benefits are payable to the limits described in this brochure. *This Excess provision is not applicable in CO, CT, ID, IL, NC, OK and SD, and benefits are payable to the limits described in this brochure. ACCIDENTAL DEATH AND ACCIDENTAL DISMEMBERMENT BENEFITS Accidental Death Benefit Maximum Amount: $15,000 If Injury to the Insured results in death within 365 days of the date of the accident that caused the Injury, the Company will pay 100% of the Accidental Death Maximum Amount. Accidental Dismemberment Benefit Maximum Amount: $30,000 If Injury to the Insured results, within 365 days of the date of the accident that caused the Injury, in any one of the Losses specified below, the Company will pay the percentage of the Accidental Dismemberment Maximum Amount shown below for that Loss. For Loss Of: Percentage of Maximum Amount Accidental Dismemberment Both Hands or Both Feet % Sight of Both Eyes % One Hand and One Foot % One Hand and the Sight of One Eye % One Foot and the Sight of One Eye % Speech and Hearing in Both Ears % One Hand or One Foot... 50% The Sight of One Eye... 50% Speech or Hearing in Both Ears... 50% Hearing in One Ear... 25% Thumb and Index Finger of the Same Hand... 25% Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of sight of an eye means total and irrecoverable loss of the entire sight in that eye. Loss of hearing in an ear means total and irrecoverable loss of the entire ability to hear in that ear. Loss of speech means total and irrecoverable loss of the entire ability to speak. Loss of thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits. If more than one Loss is sustained by an Insured as a result of the same accident, only one amount, the largest, will be paid. HEART AND/OR CIRCULATORY BENEFIT* (This benefit is not payable in addition to the Accidental Death Benefit.) Heart and/or Circulatory Benefit Maximum Amount: $10,000 If an Insured suffers a heart and/ or circulatory malfunction that results in death as a direct result of participating in a covered activity, the Company will pay the Heart and/or Circulatory Maximum Amount provided that: (1) the symptom(s) of such malfunction(s) is (are) first medically treated while the Policy is in force with respect to such Insured and within 48 hours after such participation, and (2) such Insured has not, within the last 5 years prior to the date of such participation in the covered activity, been diagnosed with, or received any medication for any myocardial infarction, angina pectoris, coronary thrombosis or a cerebral vascular incident. *The Heart and/or Circulatory Benefit is not available in CT. DEFINITIONS (Definitions may vary depending on state of issue. Please refer to the Policy on file with Policyholder.) Injury means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that is external to the body and that occurs while the injured person s coverage under the Policy is in force; (2) which occurs while such person is participating in a covered activity; and (3) which directly (independent of sickness, disease or any other cause) causes a covered loss. Insured means a person: (1) who is a member of an eligible class of persons as described in the Classification of Eligible Persons section of the Master Application in the Policy on file with the District/School ( the Policyholder/the Participating Organization ); (2) for whom premium has been paid; and (3) while covered under the Policy. Medically Necessary* means a Covered Accident Medical Service that: (1) is essential for diagnosis, treatment or care of the Injury for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; and (3) is ordered by a physician and performed under his or her care, supervision or order. *This definition is not applicable to coverage in MT. Usual and Customary Charge(s) (U&C) means a charge that: (1) is made for a Covered Accident Medical Service; (2) does not exceed the usual level of charges for similar treatment, services or supplies in the locality where the expense is incurred; or (3) is a negotiated fee; and (4) does not include charges that would not have been made if no insurance existed.

3 EXCLUSIONS AND LIMITATIONS (Exclusions may vary depending on state of issue. Please refer to the Policy on file with Policyholder.) No coverage shall be provided under the Policy and no payment shall be made for any loss resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks: 1. suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally selfinflicted Injury or autoeroticism. 2. sickness, or disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly from either of these. 3. the Insured s commission of or attempt to commit a crime. 4. infections of any kind regardless of how contracted, except bacterial infections that are directly caused by botulism, ptomaine poisoning or an accidental cut or wound independent and in the absence of any underlying sickness, disease or condition including but not limited to diabetes. This exclusion is not applicable to coverage in CO. 5. declared or undeclared war, or any act of declared or undeclared war, except if specifically provided by the Policy. 6. participation in any team sport or any other athletic activity, except participation in a covered activity. 7. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded). 8. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured is: a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft or c. (Not applicable to coverage in CO) riding as a passenger in an aircraft owned, leased or operated by the Policyholder/the Participating Organization or the Insured s employer. 9. the Insured being under the influence of intoxicants. while operating any vehicle or means of transportation or conveyance. This exclusion is not applicable to coverage in CO, MI, SD and VT. 10. the Insured being under the influence of drugs unless taken under the advice of and as specified by a physician. This exclusion is not applicable to coverage in MI and VT. 11. the medical or surgical treatment of sickness, disease, mental incapacity or bodily infirmity whether the loss results directly or indirectly from the treatment. This exclusion is not applicable to coverage in CO. 12. stroke or cerebrovascular accident or event; cardiovascular accident or event; myocardial infarction or heart attack; coronary thrombosis; aneurysm. This exclusion is not applicable to coverage in CO. 13. any condition for which the Insured is entitled to benefits under any Workers Compensation Act or similar law. 14. the Insured riding in or driving any type of motor vehicle as part of a speed contest or scheduled race, including testing such vehicle on a track, speedway or proving ground. This exclusion is not applicable to coverage in CO. 15. repair or replacement of existing artificial limbs, artificial eyes or other prosthetic appliances or rental of existing durable medical equipment unless due to a covered Injury.* 16. new, or repair or replacement of, dentures, bridges, dental implants, dental bands or braces or other dental appliances, crowns, caps, inlays or onlays, fillings or any other treatment of the teeth or gums, except for repair or replacement of sound natural teeth damaged or lost as a result of Injury up to the Dental Maximum shown in the Benefit Schedule.* 17. new eye glasses or contact lenses or eye examinations related to the correction of vision or related to the fitting of glasses or contact lenses, unless due to a covered Injury; or repair or replacement of existing eyeglasses or contact lenses unless due to a covered Injury.* 18. new hearing aids or hearing examinations unless due to a covered Injury; or repair or replacement of existing hearing aids unless due to a covered Injury.* 19. rental of durable medical equipment where the total rental expense exceeds the usual purchase expense for similar equipment in the locality where the expense is incurred (but if, in the Company s sole judgment, accident medical expense benefits for rental of durable medical equipment are expected to exceed the usual purchase expense for similar equipment in the locality where the expense is incurred, the Company may, but is not required to, choose to consider such purchase expense as a Usual and Customary covered accident medical expense in lieu of such rental expense).* 20. any charge for medical care for which the Insured is not legally obligated to pay.* 21. care, treatment or services provided by an Insured or by an immediate family member.* 22. routine physical exam and related medical services.* 23. personal comfort or convenience items, such as but not limited to, hospital telephone charges, television rental, or guest meals while confined in a hospital.* 24. elective treatment or surgery.* 25. experimental or investigational treatment or procedures.* This exclusion is not applicable to coverage in CT. 26. treatment for temporomandibular dysfunction.* This exclusion is not applicable to coverage in FL, and NM. 27. care, treatment or services provided by persons retained or employed by the Policyholder/the Participating Organization or for supplies, prescriptions or medicines paid for or reimbursable by the Policyholder/the Participating Organization or for which a charge is not made.* 28. mental illness, psychological or psychiatric counseling of any kind, mental and nervous disease or disorders and rest cures.* 29. educational or vocational testing or training.* 30. treatment of Osgood-Schlatter s disease.* 31. detached retina unless due to an Injury.* 32. diagnostic tests or treatment, except due to infection which occurs directly from an accidental cut or wound or ingestion of contaminated food.* 33. plastic or cosmetic surgery, except due to a covered Injury.* 34. charges that are payable under motor vehicle medical benefits.* This exclusion is not applicable to coverage in ID. 35. hernia except as a result of participation in a covered activity.* *This exclusion is applicable to Accident Medical Expense Benefit only.

4 ACCIDENT INSURANCE COVERAGE PROVIDING A MAXIMUM OF $25,000 ACCIDENT MEDICAL EXPENSES If an Insured suffers an Injury that, within 90 days of the date of the accident that caused the Injury, requires him or her to be treated by a physician, the Company will pay the coinsurance percentage of the Usual and Customary Charges (U&C) incurred for Medically Necessary Covered Accident Medical Services received due to that Injury up to an overall maximum of $25,000. Benefits are payable for charges incurred within 52 weeks after the date of the accident causing the Injury. Benefits are payable on an excess basis where applicable. ACCIDENT MEDICAL EXPENSE BENEFITS Covered Accident Medical Service(s) means any of the following services: INPATIENT HOSPITAL SERVICES Hospital s most common charge for semi-private room and board (or room and board in an intensive care unit) Hospital ancillary services (including, but not limited to, use of the operating room) OUTPATIENT HOSPITAL SERVICES Hospital emergency room or ambulatory medical center Laboratory tests Radiological procedures PHYSICIAN SERVICES (INPATIENT OR OUTPATIENT) Services of a Physician (Physician means a licensed practitioner of the healing arts acting within the scope of his or her license who is not: 1) the Insured; 2) an immediate family member; or 3) retained by the Policyholder/the Participating Organization.) Anesthetics and the administration of anesthetics Physical therapy ADDITIONAL SERVICES Private duty nursing by a registered nurse (R.N.) or Licensed Practical Nurse (LPN) Ambulance service to or from a hospital Rental of durable medical equipment Artificial eyes or other prosthetic appliances Medicines or drugs administered by a physician or that can be obtained only with a physician s written prescription Dental treatment (repair or replacement of sound natural teeth damaged or lost as a result of Injury) Deferred dental treatment benefits (not subject to the overall Accident Medical Expense Maximum) BENEFIT SCHEDULE* PLAN A up to a maximum of $2,000 except that an office visit connected with any such service is payable up to $50 per visit up to a maximum of 5 visits up to a maximum of $800 *The amount of benefits provided depends upon the plan selected. Premium will vary with the plan selected. up to a maximum of $500 per accident up to $600 for required dental treatment that must be postponed to a date more than 52 weeks after the date of that Injury due to the physiological changes occurring to an Insured who is a growing child. Charges incurred for deferred dental treatment are covered only if they are incurred on or before the Insured s 21st birthday; except that charges incurred for deferred root canal therapy are covered only if they are incurred within 104 weeks after the date the Injury is sustained. PLAN B up to a maximum of $1,500 except that an office visit connected with any such service is payable up to $35 per visit up to a maximum of 5 visits up to a maximum of $500 up to a maximum of $250 per accident up to $600 for required dental treatment that must be postponed to a date more than 52 weeks after the date of that Injury due to the physiological changes occurring to an Insured who is a growing child. Charges incurred for deferred dental treatment are covered only if they are incurred on or before the Insured s 21st birthday; except that charges incurred for deferred root canal therapy are covered only if they are incurred within 104 weeks after the date the Injury is sustained. LIMITATION ON MULTIPLE COVERED ACTIVITIES If an Insured person s Injury is caused by an accident that occurs while the Insured is participating in more than one covered activity applicable to that Insured, and if the same benefit applies to that Insured with respect to more than one such covered activity, then for Policy purposes the Maximum Amount for that benefit for that Insured for that accident will be determined as though the accident occurred while the Insured was participating in only one such covered activity, the one with the largest Maximum Amount for that benefit for that person. PENALTY FOR NON-COMPLIANCE* In the event that an Insured is eligible under the Policy for benefits in excess of other coverage and the Insured has other coverage that is primary under a health maintenance organization, preferred provider organization or similar health service program, a penalty will apply if he or she does not use the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. In such case, the benefits otherwise payable under the Excess provision in the Policy will be reduced by 50%. This reduction shall not apply to emergency treatment required within 24 hours of an accident when the accident occurs outside the geographic area served by a health maintenance organization, preferred provider organization or similar health service program. *This provision is not applicable in CO, CT, ID, IL, ME, NC, OK and SD.

5 STATE SPECIFIC VARIATIONS (Other state variations may apply. Please refer to the Policy on file with the Policyholder.) If you live in Alabama Exclusion #9 shall state: the Insured being intoxicated under the applicable law of the jurisdiction where the accident occurred while operating any vehicle or means of transportation or conveyance. If you live in Alaska Usual and Customary Charge(s): Information concerning the usual level of charges will be obtained from Medical Data Research (MDR). The Company will make final payment based on the calculation of the percentile of Usual and Customary Charges multiplied by the co-insurance percentage as shown on the Benefit Schedule. The Insured is responsible for charged amounts in excess of Usual and Customary Charges. Accident Medical Expense Benefits are subject to Appeal and Grievance Procedures as required by the State of Alaska. For a complete copy of these procedures contact AIG, Education Markets If you live in Arizona Coverage is not Medicare Supplement. Covered Accident Medical Services include home health services performed by a licensed home health agency, prescribed by a physician in lieu of hospital services, providing the hospital services would have been covered. Home health services are covered at (Plan A) or (Plan B) and subject to all other provisions of the Accident Medical Expense Benefit. If you live in Colorado Injury means bodily injury caused by an accident that: (1) occurs while the Policy is in force as to the person whose injury is the basis of claim; (2) occurs while such person is participating in a covered activity; and (3) results directly and independently of all other causes in a covered loss. Exclusion #1 shall state: suicide or any attempt at suicide or intentionally self inflicted injury or any attempt at intentionally self inflicted injury, while sane. Exclusion #2 shall state: sickness, disease or infections of any kind; except bacterial infections due to an accidental cut or wound, botulism or ptomaine poisoning. Exclusion #3 shall state: the Insured s commission of or attempt to commit a felony. THIS IS A SUPPLEMENTAL POLICY THAT IS NOT INTENDED TO PROVIDE THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). UNLESS YOU HAVE ANOTHER PLAN (SUCH AS MAJOR MEDICAL COVERAGE) THAT PROVIDES MINIMUM ESSENTIAL COVERAGE IN ACCORDANCE WITH THE ACA, YOU MAY BE SUBJECT TO A FEDERAL TAX PENALTY. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE. If you live in Connecticut Exclusion #9 shall state: the Insured being intoxicated under the applicable law of the jurisdiction where the accident occurred while operating any vehicle or means of transportation or conveyance. Exclusion #10 shall state: the Insured voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless as prescribed by the Insured s physician for the Insured. The Covered Accident Medical Services for semi-private room and board shall include the following: If an insured is confined as an inpatient in a hospital resulting from accidental ingestion of a controlled drug, the period of confinement for which benefits will be payable shall be at least thirty days in any calendar year and if the Insured incurs covered expenses while not confined in a hospital, benefits will be payable in any calendar year up to a maximum of $500. Covered Accident Medical Services include home health care as provided by a home health agency and in accordance with Connecticut law. Home health care is covered at (Plan A) or (Plan B) and subject to all other provisions of the Accident Medical Expense Benefit. If you live in Florida Usual and Customary Charge(s) means the charge, fee or expense which is the smallest of: (a) the actual charge of the Covered Service; (b) the charge usually made for a Covered Service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the survey by MDR of prevailing charges made for a Covered Service in the geographic area by those of similar professional standing, the results of which are used to develop a range of fees for each service. With respect to item (d) above, Usual and Customary Charges means the 80th percentile of the payment system in effect on the Effective Date shown in the Schedule of Benefits. Covered Accident Medical Services include any inpatient hospital, ambulatory surgical center and general anesthesia services or charges due to Injury if the Insured: (a) is under 8 years of age or is determined by a licensed dentist and the Insured s physician to require necessary dental treatment or surgery in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or (b) has one or more medical condition that would create significant or undue medical risk for the Insured in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital of ambulatory surgical center. The following Extension of Benefits applies: If an Insured is totally disabled due to Injury on the date the Policy terminates, coverage will continue until the earliest of the end of the 90 day period following the date the Policy terminates, the date when the applicable Maximum Benefit Amount is reached and the date the Insured is no longer totally disabled. The following Extension of Benefits for Dental Coverage applies: The Company will continue to pay Dental Benefits for a specific dental injury following the termination of the Insured s coverage under the Policy if all of the following conditions are met: (a) The course of treatment or dental procedures were recommended in writing by the Insured s physician or dentist and began in connection with a specific accident that occurred while the Insured s coverage was in effect under the Policy. (b) The dental procedures were for other than routine examinations, prophylaxis, X-rays, sealants or orthodontic services. (c) The Insured s termination was not voluntary. This Extension of Benefits for Dental Coverage will terminate on the earlier of: (a) The expiration of 90 days following the Insured s termination of coverage; and (b) The date the Insured becomes covered under the succeeding policy or contract providing coverage for similar dental procedures. The Penalty for Non-Compliance provisions shall state: In the event that an Insured is eligible under the Policy for benefits in excess of other coverage and the Insured has other coverage that is primary under a health maintenance organization, preferred provider organization or similar health service program, a penalty will apply if he or she does not use the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. In such case, the benefits otherwise payable under the Excess provision in the Policy will be reduced by 50%. This reduction shall not apply to an Insured in connection with any treatment for which the health maintenance organization, preferred provider organization or similar health service program provides coverage as if the Insured used the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. If you live in Idaho IMPORTANT CONSUMER SERVICE INFORMATION REGARDING YOUR INSURANCE In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was involved in the sale of this insurance, or if you have additional questions, you may contact the insurance company issuing this insurance at the following address and telephone number: NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA Customer Service Accident & Health Claims Department P.O. Box Wilmington, DE If you have been unable to obtain satisfaction from the insurance company or the agent or both you should contact the Idaho Department of Insurance at: Idaho Department of Insurance Consumer Affairs 700 W. State Street, 3rd Floor P.O. Box Boise, ID or Written correspondence is preferable so that a record of your inquire is maintained. When contacting your agent, the insurance company, or the Idaho Department of Insurance, have your policy number available. If you live in Indiana The Heart and/or Circulatory Benefit shall state: If an Insured suffers a heart and/or circulatory malfunction that results in death as a direct result of participating in a covered activity, the Company will pay the Heart and/ or Circulatory Maximum Amount provided that the symptom(s) of such malfunction(s) is (are) medically treated while the Policy is in force with respect to such Insured and within 48 hours after such participation.

6 STATE SPECIFIC VARIATIONS CONTINUED (Other state variations may apply. Please refer to the Policy on file with the Policyholder.) Covered Accident Medical Services include artificial limbs, artificial eyes, other prosthetic appliances, or repair or replacement of the prosthesis if the accident causes damage to the prosthesis. These services are covered at (Plan A) or (Plan B) and subject to all other provisions of the Accident Medical Expense Benefit. If you live in Kansas Exclusion #13 shall state: any condition for which the Insured is entitled to benefits under any Workers Compensation Act or similar law. If the Insured enters into settlement giving up his or her right to recover future medical benefits under a Workers Compensation law, the policy will not pay those medical benefits that would have been payable in absence of that settlement. If you live in Maine The Claims Procedure shall state: The Company must be notified of a loss within 30 days of such accident. If you live in Massachusetts Please note the following disclosure: This plan alone does not meet Minimum Creditable Coverage standards and will not satisfy the individual mandate that you have health insurance. If you live in Michigan Please read the following Notice: The Policy does not provide comprehensive major medical coverage and does not satisfy the minimum essential coverage requirement of the Affordable Care Act. If you live in Mississippi The Claims Procedure shall state: The Company must be notified of a loss within 30 days of such accident. If you live in Missouri Injury means bodily injury: (1) which is sustained as a direct result of an accident that occurs while the injured person s coverage under the Policy is in force; (2) which occurs while such person is participating in a covered activity; and (3) which directly (independent of sickness, disease or any other cause) causes a covered loss. Exclusion #1 shall state: suicide or any attempt at suicide while sane or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury or autoeroticism. Covered Accident Medical Services include hospital or ambulatory surgical center ancillary services (including but not limited to, use of the operating room. These services are covered at (Plan A) or 65% of U&C (Plan B) and subject to all other provisions of the Accident Medical Expense Benefit. If you live in Montana Usual and Customary Charge(s) means a charge that: (1) is made for a Covered Accident Medical Service; (2) does not exceed the usual level of charges for similar treatment, services or supplies in the locality where the expense is incurred; or (3) is a negotiated fee; and (4) does not include charges that would not have been made if no insurance existed. Information concerning the range of fees will be obtained from Fair Health, Inc. The Company will pay the fee charged, up to the 85th percentile of the range of fees for each service. If you live in New Mexico Covered Accident Medical Services include treatment of craniomandibular or temporomandibular joint disorders if due to an accidental Injury. These services are covered at (Plan A) or (Plan B) and subject to all other provisions of the Accident Medical Expense Benefit. If you live in North Carolina The Claims Procedure shall state: Claims for benefits must be filed within 180 days from date of accident, or as soon as reasonably possible. Exclusion #20 shall state: any charge for medical care for which the Insured is not legally obligated to pay except for any payment under section 1902 of the Social Security Act. Exclusion #26 shall state: non-surgical treatment for temporomandibular dysfunction over $3, Exclusion #36 shall state: Services or supplies for the treatment of an occupational injury which are paid under the North Carolina Workers Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers compensation insurance carrier according to a final adjudication under the North Carolina Workers Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers Compensation Act. If you live in Oklahoma Exclusion #5 shall state: war or acts of war, declared or undeclared, while serving in the military service or any auxiliary unit. If you live in South Carolina Exclusion #16 shall state: new, or repair or replacement of, dentures, bridges, dental implants, dental bands or braces or other dental appliances, crowns, caps, inlays or onlays, fillings or any other treatment of the teeth or gums, except for repair or replacement of sound natural teeth (includes natural teeth that have been restored to their normal function) damaged or lost as a result of Injury up to the Dental Maximum shown in the Benefit Schedule. If you live in South Dakota Exclusion #10 shall state: the Insured being under the influence of drugs or intoxicants during the Insured s commission of a felony. Exclusion #13 shall state: any condition for which benefits are paid to the Insured under any Workers Compensation Act or similar law. Exclusion #21 shall state: care, treatment or services provided by an Insured or by an immediate family member. If the immediate family member is the only physician in the area, coverage will be permitted if the physician is acting within his/her scope of practice. The Heart and/or Circulatory Benefit shall state: If an Insured suffers a heart and/or circulatory malfunction that results in death as a direct result of participating in a covered activity, the Company will pay the Heart and/ or Circulatory Maximum Amount provided that: (1) the symptom(s) of such malfunction(s) is (are) first medically treated while the Policy is in force with respect to such Insured and within 48 hours after such participation, and (2) such Insured has not, within the last 6 months prior to the date of such participation in the covered activity, been diagnosed with, or received any medication for any myocardial infarction, angina pectoris, coronary thrombosis or a cerebral vascular incident. If you live in Texas Texas Department of Human Services Reimbursement: Benefits paid on behalf of an Insured must be paid to the Texas Department of Human Services, if such Insured is eligible for benefits under the Accident Medical Expense Benefit and is also entitled for benefits for the same expense from the Texas Department of Human Services. If you live in Vermont The following provision shall be added to Accidental Dismemberment Benefit: In no event will any Reduction Schedule provision or percentage of Principal Sum provision operate to reduce the percentage payable to less than $5,000 for loss of life or double dismemberment or $2,500 for single dismemberment. Injury means bodily injury: (1) which is sustained as a direct result of an unintended, unanticipated accident that occurs while the injured person s coverage under the Policy is in force; (2) which occurs while such person is participating in a covered activity; and (3) which is not the result of disease or bodily infirmity and directly causes a covered loss. Exclusion #3 shall state: the Insured s commission of or attempt to commit a felony. If you live in Virginia The Penalty for Non-Compliance provision shall state: In the event that an Insured is eligible under the Policy for benefits in excess of other coverage and the Insured has other coverage that is primary under a health maintenance organization, preferred provider organization or similar health service program, a penalty will apply if he or she does not use the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. In such case, the benefits otherwise payable under the Excess provision in the Policy will be reduced by 50%. This reduction shall not apply to an Insured in connection with any emergency treatment whether or not the health maintenance organization, preferred provider organization or similar health service program provides coverage as if the Insured used the facilities or services of the health maintenance organization, preferred provider organization or similar health service program. If you live in West Virginia Exclusion #4 shall state: infections of any kind regardless of how contracted, except bacterial infections that are directly caused by botulism, ptomaine poisoning and in the absence of any underlying sickness, disease or condition including but not limited to diabetes. If you live in Wisconsin NOTICE: Claim settlement is based on a specific methodology and benefit payment may be less than the provider s billed charge. KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem. NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA Customer Service Accident & Health Claims Department P. O. Box Shawnee Mission, KS You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE a state agency which enforces Wisconsin s insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting: Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI If you live in Wyoming Medically Necessary means a medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that: (1) is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury; (2) provides for the diagnosis, direct care and treatment of the patient s condition, illness, disease or injury; (3) is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and (4) is not primarily for the convenience of the patient, physician or other health care provider. A medical service, procedure or supply shall not be excluded from being a medical necessity under this section solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by: (1) peer reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health s Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE) or (2) medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act.

7 ENROLLMENT FOR STUDENT ACCIDENT INSURANCE PLAN (Excluding Senior High School Interscholastic Football and/or Sports) Insurance Underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. PLEASE PRINT CLEARLY Person to be Insured HOME LAST NAME FIRST NAME MI DATE OF BIRTH ADDRESS STREET ADDRESS CITY OR TOWN COMPANY USE ONLY STATE ZIP CODE DATE OF APPLICATION (MM/DD/YYYY) GRADE STUDENT S SOCIAL SECURITY NUMBER (optional) - - HOLDER NUMBER NAME OF SCHOOL TELEPHONE NUMBER By signing below, I acknowledge that I have read, understand and agree to the terms and conditions of this coverage as detailed in this Student Accident POLICY NUMBER NAME OF SCHOOL DISTRICT/DIOCESE Insurance Plan brochure. There is no obligation to purchase this insurance plan. SIGNATURE OF PARENT OR GUARDIAN COV CD K-12 PLAN A PLAN B COV CD K-12 PLAN A PLAN B School Time Accident Coverage n $30.00* n $26.00* 24-Hour Accident Coverage n $112.00* n $102.00* * Annual Premium Please check applicable coverage(s) above and enclose the correct amount. TOTAL ENCLOSED: CHECK # Please make money order or check payable to: National Union Fire Insurance Company of Pittsburgh, Pa. AS-XS (PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS)

8 FROM CITY STATE ZIP Return to: National Union Fire Insurance Company of Pittsburgh, Pa. Voluntary K-12 P.O. Box Philadelphia, PA

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