Kids will be Kids! Available Coverage Options

Transcription

1 Available Cverage Opins Depending n which prgram yur schl prvides, sme r all f he fllwing vlunary insurance prducs are available fr purchase n a vlunary basis: $500,000 Schl Time Only Suden Acciden Insurance $500,000 Rund The Clck 24 Hur Acciden Cverage $10,000 Suden Life Insurance $5,000 Suden Denal Acciden Insurance Kids will be Kids! 1. Make sure yur child is prperly cvered agains unfreseen accidens. 2. Purchase cverage a yur cnvenience frm any cmpuer. 3. Fllw he easy sep by sep insrucins and yu re dne in minues! These Vlunary Paricipain Suden Acciden Insurance Plans ffered hrugh yur schl can be purchased easily nline a:

2 24 Hur Suden Acciden Insurance Plan $500,000 MAXIMUM BENEFIT SCHOOL TIME ONLY COVERAGE Yur child s schl has purchased grup suden acciden insurance cverage fr all sudens prviding valuable precin agains accidenal injuries ccurring schl hurs r during schl spnsred and supervised aciviies. EXTENDED PROTECTION FOR YOUR CHILD This 24-hur pin gives yu he ppruniy exend yur child s schl ime nly cverage a full 24 hurs a day wih all he same benefis and resricins f yur child s schl plan. This way yur child will be cvered agains accidens ccurring anyime; evenings, weekends, hlidays, - even during he acive summer vacain mnhs up $500,000. ACCIDENT COVERAGE This plan cvers medical expenses incurred frm accidenal bdily injuries including bu n limied : 1) brken arm frm falling ff bicycle, 2) cncussin frm being hi in he head, r 3) laceraed f frm sepping n brken glass. This plan des n cver medical expenses frm sicknesses such as measles, mumps, r he flu. PLEASE NOTE: injuries frm inerschlasic ahleic aciviies are n cvered under his plan if yur child s schl has purchased an Ahleic Acciden Plan. This plan cvers accidenal bdily injuries resuling in deah and dismembermen. The payable benefi amun fr accidenal deahs is $10,000. The payable benefi amun fr accidenal dismembermen is up $20,000 - he acual amun will be deermined accrding he dismembermen scheduled lised in he Plicy. The Expsure and Disappearance Benefi included n he Plicy exends cverage fr he fllwing: Expsure - If an Insured is expsed weaher because f an Acciden and his resuls in deah, he Insured will be eligible fr he applicable accidenal deah benefi.; Disappearance - If he cnveyance in which an Insured is riding disappears, is wrecked, r sinks, and he Insured is n fund wihin 365 days f he even, We will presume ha he persn ls his r her life as a resul f injury and he Insured will be eligible fr he applicable accidenal deah benefi. BENEFITS ADDITIONAL TO OTHER COVERAGE This 24-hur plan will reimburse yur financial lss semming frm cvered accidenal injuries, up he plicy limis, regardless f any her cverage yu may have (excep fr injuries cvered under he schl s schl-ime plicy). BENEFITS: are prvided fr accidenal injuries fr which medical reamen by a physician, surgen, denis, r regisered nurse, hspial service, ambulance services, f X-rays are rendered. The iniial reamen mus be rendered wihin 90 days f acciden and benefis are limied reamen rendered wihin 260 weeks f he dae f acciden. All claims mus be submied he cmpany wihin 90 days frm he dae f acciden. MAXIMUM The maximum benefi payable fr medical expenses as a resul f any ne acciden is $500,000. COVERED MEDICAL EXPENSES Cverage under he Acciden Medical Expense Benefi applies he fllwing Medical Services resuling frm a Cvered Injury. Hspial Rm and Bard are cvered up he Usual and Cusmary charges. Ancillary Hspial Expenses including peraing rm, labrary ess, aneshesia and medicines (excluding ake hme drugs) when Hspial Cnfined are cvered up $5,000 f he Usual & Cusmary charges. Medical Emergency Care (rm and supplies) expenses incurred wihin weny-fur hurs f an acciden are cvered up $100 f he Usual & Cusmary charges.

3 Oupaien Surgical Rm (includes Ambulary Surgical Faciliies) are cvered up $1,000 f he Usual & Cusmary charges. Oupaien diagnsic X-rays, labrary prcedures and ess are cvered up $750 f he Usual and Cusmary charges. Physician nn-surgical reamen/examinain expenses (excluding medicines) including he physician s iniial visi, each necessary fllw-up visi and cnsulain visis when referred by he aending physician are cvered up $250. Physician s surgical expenses are cvered up $5,000 f he Usual and Cusmary charges. If a cvered injury requires muliple surgical prcedures during he same peraive sessin hrugh he same r differen incisin, We will pay nly ne benefi, he larges f he prcedures perfrmed. Assisan physician expenses, when medically necessary, are cvered up he Usual and Cusmary charges. Regisered nurse services, when medically necessary, (he nurse cann be a member f he insured s immediae family) are cvered up $350. Aneshesilgis expenses are cvered up 30% f Surgery expense. Physiherapy expenses n an inpaien r upaien basis limied ne (1) visi per day a maximum f en (10) visis. Expenses include reamen and ffice visis cnneced wih such reamen when prescribed by a Physician, including diahermy, ulrasnic, whirlpl, r hea reamens, adjusmens, manipulain, massage r any frm f physical herapy are cvered up $500. Nn-emergency inpaien and upaien X-ray expenses (including reading charges) bu n fr denal X-rays unless Medically Necessary evaluae a Cvered Injury are cvered up $200 f he Usual and Cusmary charges. Radilgical prcedures are cvered up he Usual and Cusmary charges. Diagnsic imaging expenses including MRI and CAT Scan are cvered up $750 f he Usual and Cusmary charges. Ambulance expenses fr ransprain frm he emergency sie he Hspial are cvered up $1,000 f he Usual and Cusmary charges. Rehabiliaive limb braces, wheelchairs and her medical equipmen r appliances prescribed by a Physician are cvered up $2,500 f he Usual and Cusmary charges. Prescripin drug expenses, fr Cvered Injuries, prescribed by a Physician and adminisered n an upaien basis are cvered up he Usual and Cusmary charges. Expenses fr bld and bld ransfusins; xygen and is adminisrain are cvered up he Usual and Cusmary charges. Denal expenses, fr Cvered Injuries, are cvered up $4,000 f he Usual and Cusmary charges. Eyeglasses, cnac lenses r hearing aids damaged r desryed as a resul f a Cvered Injury and prescribed by a Physician are cvered up $1,000 f he Usual and Cusmary charges. EXCLUSIONS GENERAL EXCLUSIONS A lss will n be a Cvered Lss if i is caused by, cnribued, r resuls frm: 1. suicide r any aemp a suicide r ineninally self-infliced injury r any aemp a ineninally self-infliced injury. 2. war r any ac f war, wheher declared r undeclared. 3. invlvemen in any ype f acive miliary service. 4. illness r disease; medical r surgical reamen f illness r disease; r cmplicains fllwing he surgical reamen f illness r disease; excep fr Accidenal ingesin f cnaminaed fds. 5. paricipain in he cmmissin r aemped cmmissin f any felny. 6. Parasailing, bungee jumping, heli-skiing, scuba diving r any her exra-hazardus aciviy. 7. being inxicaed. a. An Insured will be cnclusively presumed be inxicaed if he level f alchl in his r her bld exceeds he amun a which a persn is presumed, under he law f he lcale in which he Acciden ccurred, be inxicaed, if peraing a mr vehicle. b. An aupsy repr frm a licensed medical examiner, law enfrcemen fficer reprs, r similar iems will be cnsidered prf f he Insured's inxicain. 8. being under he influence f any narcic, unless adminisered r cnsumed n he advice f a Physician. 9. ravel r fligh in any aircraf excep as a fare-paying passenger n a regularly scheduled charer r cmmercial fligh. 10. a cardivascular even r srke caused by exerin prir r a he same ime as an Acciden. 11. paricipain in any eam spr r any her ahleic aciviy unless menined in he Cvered Aciviies. 12. he Insured riding in r driving any ype f mr vehicle as par f a speed cnes r scheduled race, including esing such vehicle n a rack, speedway r prving grund. AME EXCLUSIONS In addiin he General Exclusins saed in he Plicy, We will n cver expenses under his addiinal benefi fr: 1. Fighing r brawling excep in self-defense. 2. Any expense fr which benefis are payable under Caasrphic Acciden Insurance Prgram f he Sae High Schl Inerschlasic Aciviies Assciain, r any sae equivalen. 3. Reinjury f he same bdy par wihin 6 mnhs f he Cvered Acciden unless previusly cleared by a Physician pracice r play. 4. Csmeic, plasic r resraive surgery unless Medically Necessary fr he reamen f he Cvered Injury. 5. Any medical expenses relaed pregnancy unless Medically Necessary fr he reamen f he Cvered Injury. 6. Any expenses fr a Pre-exising Cndiin. 7. Cvered Injury fr which he Insured is eniled benefis under Wrkers Cmpensain Benefis, Emplyer Liabiliy Law, r any saury mandaed cverage. 8. Persnal cmfr r cnvenience iems, such as bu n limied Hspial elephne charges, elevisin renal, r gues meals. 9. Treamen by any immediae family member r member f he Insured's husehld.

4 10. Expenses incurred fr denal care, reamen, repair r replacemen f sund naural eeh unless Medically Necessary fr he reamen f he Cvered Injury. 11. Expenses incurred fr eye examinains, eye glasses, cnac lenses r hearing aids r he fiing, repair r replacemen f hese iems unless Medically Necessary fr he reamen f he Cvered Injury. 12. A hernia. 13. Ruine physical examinains and relaed medical services, r elecive reamen r surgery r experimenal r invesigaive reamens r prcedures. 14. Expenses incurred fr psychlgical r psychiaric cunseling f any kind r any expense fr reamen f menal r nervus diseases r disrders. 15. Expenses which he Insured is n legally bligaed pay. 16. Expenses fr Cusdial Services r services prvided by a privae duy nurse unless such expenses are incurred as a resul f a Cvered Injury. 17. Expenses relaed he repair r replacemen f exising arificial limbs, eyes, r her prsheic appliances, r renal f exising medical equipmen unless fr he purpse f mdifying he iem because he Cvered Injury has caused furher impairmen f he underlying bdily cndiin. 18. Treamen invlving cndiins caused by repeiive min injuries r cumulaive rauma and n a resul f a Cvered Injury. 19. Treamen fr sechndriis due veruse and ccurring during perids f rapid grwh, including bu n limied Osgd-Schlaer Disease. CLAIM PROCEDURE In he even f a claim, ccurring her han during schl hurs, nify Bllinger by calling r prin a claim frm direcly frm ur websie (Ne: Claims ccurring during schl hurs fall under he schl plicy. Fr such claims yu can bain a claim frm frm he schl.) ID CARD STUDENT ACCIDENT INSURANCE Name: Sree Address: Twn: Ciy: Sae: Zip: Schl Disric: T bain a claim frm, please visi Underwrien by: Preferred Prvider Newrk: Adminisered by: P.O. Bx 1346, Mrriswn, NJ Please sre yur card in a safe lcain fr fuure reference. DO NOT RETURN THE ENROLLMENT FORM TO THE SCHOOL. Make yur check r mney rder payable BOLLINGER, INC. Mail he frm and he apprpriae premium : Bllinger Specialy Grup, PO Bx 1515, Mrriswn, NJ Yur cancelled check is yur receip.

5 SCHOOL SPONSORED STUDENT ACCIDENT INSURANCE PLAN COST PER SCHOOL YEAR 24-HOUR ROUND THE CLOCK PLAN $92.00 Cverage hrugh he las day f summer vacain This is inended as a general descripin f cerain ypes f insurance and services available qualified cusmers hrugh he Zurich American Insurance Cmpany (1400 American Lane, Schaumburg, IL 60196, phne number , NAIC # 16535, dmiciled in New Yrk) slely fr infrmainal purpses. Nhing herein shuld be cnsrued as a sliciain, ffer, advice, recmmendain, r any her service wih regard any ype f insurance prduc underwrien by Zurich American Insurance Cmpany. Yur plicy is he cnrac ha specifically and fully describes yur cverage, erms and cndiins. The descripin f he plicy prvisins gives a brad verview f cverages and des n revise r amend he plicy. Cverages and raes are subjec individual insured meeing ur underwriing qualificains and prduc availabiliy in applicable saes.

6 i l Enrllmen e Frm Blanke Acciden Insurance f f r POLICYHOLDER m INFORMATION Name f Plicyhlder: (Schl, m Disric, Dicese, ec.) Named u f individual Schl enrlled in: s ENROLLEE INFORMATION Full Legal n Name (Firs, Middle Iniial and Las): Las 4 Digis f SSN: Sree Address: Ciy: Sae: Zip Cde: b Mailing e Address (if differen frm abve): Ciy: Sae: Zip Cde: Dae f p Birh (MM/DD/YYYY): Gender: l Male aaddress: c Requesed e Effecive Dae (MM/DD/YYYY): d a PARENT b OR LEGAL GUARDIAN INFORMATION (if Enrllee is a Minr) Full Legal Name (Firs, Middle Iniial and Las): Relainship Enrllee: v Paren Legal Guardian e Sree Address (if differen han Enrllee's): Ciy: Sae: Zip Cde: Dae f h Birh (MM/DD/YYYY): e Address: l g INSURANCE REQUESTED. Benefi(s) Included: Accidenal Deah Benefi T Accidenal Dismembermen Benefi Expsure p and Disappearance Benefi Gender: Male Female Female Marial Saus: Single Married Dmesic/Civil Unin Parner Hme Phne: Hme Phne: - - Wrk Phne: Wrk Phne: - - Zurich American Insurance Cmpany 1400 American Lane Schaumburg, Illinis Cverage Amun Cell Phne: Cell Phne: - - as per he Plicy Schedule as per he Plicy Schedule as per he Plicy Schedule Acciden M Medical Expense Benefi as per he Rider a BENEFICIARY r DESIGNATION g Primary i Beneficiary: n Full Legal Name (Firs, Middle Iniial and Las): Relainship: % Share: 3 Full Legal / Name (Firs, Middle Iniial and Las): 4 " Cningen Beneficiary: Relainship: % Share: Full Legal Name (Firs, Middle Iniial and Las): Relainship: % Share: PREMIUM INFORMATION: Enrllee: $ Frequency f Paymen: Annually Mehd f Paymen: Credi Card (if purchasing nline) Bank Draf (if purchasing by mail) The Enrllee, r if he Enrllee is a minr, he Enrllee's Paren r Legal Guardian, mus cmplee a separae auhrizain frm fr a Credi Card r Bank Draf paymen. U-BMC-103-B NJ (08/11) Page 1 f 2

7 FRAUD WARNING Any persn wh includes any false r misleading infrmain n an applicain fr an insurance plicy is subjec criminal and civil penalies. The Enrllee hereby enrlls fr Acciden Insurance and declares ha: All infrmain prvided in his enrllmen frm and any aachmens here is rue and crrec he bes f my knwledge and belief. The undersigned undersands ha all infrmain prvided in his enrllmen frm and any aachmens here is maerial Zurich American Insurance Cmpany's decisin prvide his insurance, and ha insurance will be prvided in reliance upn he ruh f such infrmain. I is hereby undersd and agreed ha: 1. his insurance is prvided by Zurich American Insurance Cmpany in cnsiderain f paymen f he required premium; and 2. he insurance under he plicy begins n sner han he dae he Cmpany r is Agen apprves he Enrllmen Frm. Enrllee's Signaure (may be elecrnic): Dae: Paren r Legal Guardian's Signaure (may be elecrnic): Dae: U-BMC-103-B NJ (08/11) Page 2 f 2 MAKE YOUR CHECK OR MONEY ORDER PAYABLE TO: BOLLINGER INC. MAIL THE COMPLETED APPLICATION AND PAYMENT TO: BOLLINGER SPECIALTY GROUP PO BOX 1515 MORRISTOWN, NJ 07962