Accident and Sickness Insurance For Students

Transcription

1 ACCIDENT AND SICKNESS INSURANCE PLAN for students attending Idaho Falls, Idaho To download claim forms or a copy of this brochure. please visit underwritten by Nationwide Life Insurance Company Policy Number: Your permanent ID Card is inside. Please detach and retain for proof of coverage. No other will be issued. NLIC BR 7/08

2 Dear Student: The administration is making available to the students and their dependents a plan of blanket Accident and Sickness Insurance underwritten by Nationwide Life Insurance Company. The coverage is designed to provide benefits for medical expenses arising from an accident or illness including those which occur off campus and during interim vacations. Any questions about the policy should be directed to: Renaissance Agencies, Inc. P.O. Box 2300 Santa Monica, CA Phone Table of Contents Eligibility... 1 Premium Refunds... 1 Effective and Termination Dates... 2 Extension of Benefits... 2 Continuous Coverage... 2 Exclusions... 3 Pre-Existing Conditions Limitation... 5 Coordination of Benefits... 6 Definitions... 6 Claim Procedure... 7 Medical Benefits Schedule Certification of Qualifying Health Plan Coverage Authorized Representation Summary of Privacy Policy Nationwide Life HIPAA Notice Enrollment Form ID Card... Back Cover Terms and Costs of Coverage fall Spring Summer Term Term Term 8/18/08 1/12/09 5/18/09 to to to 1/12/09 5/18/09 8/24/09 Student Only $50.00 $50.00 $50.00 Each Dependent $89.00 $89.00 $89.00 Eligibility All students attending the College and taking 10 or more credits are eligible and will automatically be enrolled in this plan for the academic term in which they are registered. Coverage is mandatory and no waivers will be granted. Coverage will become invalid for students (and their covered dependents) who leave school within 31 days of their effective date of coverage. The Servicing Agent should be notified at that time by the student. Students who enroll in the plan may secure family coverage by completing the attached enrollment form and submitting the required premium. Eligible dependents are the lawful spouse and unmarried children under the age of 23 who are not self-supporting and reside with the insured student. An insured student s newborn child is automatically covered from the moment of birth until such child is 60 days old. Coverage for such child will be for Sickness and Injury, including congenital anomalies, prematurity and nursery care. However, the insured student must notify the Company in writing within 60 days of such birth and pay the required additional premium, if any, in order to have coverage for the newborn child continue beyond such 60 day period. Coverage for an adopted newborn that is placed with the adoptive insured student within 60 days of the adopted child s date of birth is effective from the moment of birth. Coverage for an adopted child placed with the adoptive insured student more than 60 days after the birth of the adopted child shall be from and after the date the child is placed. Coverage for such child will be for Sickness and Injury, including congenital anomalies, prematurity and nursery care. Coverage will continue unless the placement is disrupted prior to legal adoption and the child is removed from placement. However, the insured student must notify the Company in writing within 60 days of such adoption and pay the required additional premium, if any, in order to have coverage for the adopted child continue beyond such 60 day period. Dependents must be enrolled for the same term of coverage for which the insured student is enrolled. Coverage for eligible dependents will not be effective prior to that of the insured student or extend beyond that of the insured student. Premium Refunds There are no premium refunds, except when a Covered Person enters the armed forces, at which time a pro-rata refund of premium will be made upon request. 1

3 Effective and Termination Dates Coverage becomes effective at 12:01 a.m. on the later of: 1) the Policy effective date (08/18/08); 2) the first day of the term for which the proper premium has been paid; or 3) the date following the day the proper premium is received by the Business Office. All coverage terminates at 12:01 a.m. on the earliest of: 1) the Policy termination date (08/24/09); 2) the last day of the term for which premium has been paid; 3) the date when premium payment is due and unpaid; or 4) the date the Covered Person enters full-time active military service (the Company will refund the unearned pro-rata premium upon request). Please note that dependents must renew their coverage within 31 days of their previous termination date in order to maintain Continuous Coverage. It is the Covered Person s responsibility to make timely renewal payments to avoid a lapse in coverage. Eligibility requirements must be met each time premium is paid to renew coverage. There is no continuation coverage for this plan for students and/or dependents who are no longer eligible. We do not send termination or renewal notices. It is the Covered Person's responsibility to renew coverage in a timely manner, subject to continuing eligibility. Extension of Benefits If a Covered Person is Totally Disabled or pregnant on the date their coverage terminates, the Company will extend the Covered Person s benefits for Covered Charges incurred as a result of the Total Disability condition or in connection with pregnancy, childbirth or miscarriage. Extension of benefits for medically necessary covered services and supplies will end at the earliest of: 1) the end of a period of 12 months following termination of the Policy; 2) the date the Covered Person is no longer Totally Disabled or the pregnancy has terminated; or 3) the date the Lifetime Aggregate Maximum Amount, Per Injury or Sickness is reached. Dependents that are newly acquired during the insured student's Extension of Benefits period are not eligible for benefits under this provision. Continuous Coverage If a Covered Person has continuous coverage, he or she will not be denied benefits under this Policy for an Injury or Sickness which was the basis of a covered claim under the prior policy. Continuous coverage means the period of time that the student was continuously insured under the school s prior student health insurance policy with no greater than a 63-day lapse between this Policy and any of the prior policies. Benefits must not be available from the prior policy and the student must be enrolled in this Policy and pay the premium within 31 days of the expiration date of the prior student health insurance policy. For purposes of this provision, benefits for the aggravation of an old Injury will be paid on the same basis as a Sickness. Exclusions The Policy does not provide benefits for expense resulting from: 1. Services normally provided without charge by the College s student health service, infirmary, or hospital, or by health care providers employed by the College; services covered or provided by the student health fee; 2. Preventative medicines, except as specifically provided; 3. Organ transplants; 4. Injury sustained or Sickness contracted while in service of the armed forces of any country, except as specifically provided. Upon the Covered Person entering the armed forces of any country, the Company will refund the unearned pro-rata premium to such Covered Person; 5. Sickness, Accident, treatment or medical condition arising out of the play or practice of or traveling in conjunction with intercollegiate sports; 6. Cosmetic surgery, except as the result of covered Injury occurring while this Policy is in force as to the Covered Person. This exclusion shall also not apply to reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect; 7. Injury or Sickness for which benefits are paid under any Workers Compensation or Occupational Disease Law; 8. Expense incurred as the result of dental treatment. This exclusion does not apply to treatment resulting from Injury to natural teeth; 9. Expense incurred for treatment of temporomandibular joint dysfunction; 10. Medical services that are not Medically Necessary or that do not conform with medical standards of practice within the community. Also services and supplies in connection with experimental or investigational treatment; 11. Injury or Sickness resulting from declared or undeclared war or any act thereof; 12. Charges for treatment of any Injury or Sickness due to a Covered Person s commission of, or attempt to commit a felony, or a crime which would be considered a felony if prosecuted; 13. Injury due to participation in a riot; 14. Charges for which Covered Persons have no legal obligation to pay in absence of this or like coverage; 15. Services or supplies rendered by a close relative of the Covered Person. Close relative means a Covered Person s spouse, children, parents, brothers and sisters; (continued on page 4) 2 3

4 Exclusions (continued from page 3) 16. For services, supplies or treatment, including any period of hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a doctor; 17. Expenses incurred in connection with fertility, and services or supplies for inducing conception; 18. Treatment of obesity, including any care which is primarily dieting or exercise for weight loss; 19. Expense incurred for eye examinations or prescriptions, eyeglasses, and contact lenses (except for sclera shells which are intended for use of corneal bandages), eye refractions, except as required for repair caused by a covered Injury; 20. Well baby care and routine newborn infant care, except as specifically provided; 21. Routine periodical physical examinations, except as specifically provided; 22. Expenses incurred for allergy testing; 23. Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a scheduled airline maintaining regular published schedules on a regularly established route; 24. Treatment of mental or nervous disorders except as specifically provided; 25. Intentionally self-inflicted injury, including drug overdose; 26. Expense incurred for: tubal ligation; vasectomy; breast implants; breast reduction; sexual reassignment surgery; non-cystic acne; submucous resection and/or other surgical correction for deviated nasal septum, other than for required treatment of acute purulent sinusitis; circumcision; learning disabilities; and hypnotherapy; 27. Voluntary or elective abortion; 28. Alternative health care, including biofeedback-type services; 29. Hearing aids, including exams for fitting, except as required to correct damage caused by an Injury which occurs while the patient is covered by this Plan; and 30. Outpatient prescription drugs, except as specifically provided. Pre-Existing Conditions Limitation A Pre-Existing Condition means a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or Treatment was recommended or received during the six (6) months immediately preceding the Covered Person s effective date of coverage under the Policy. If a Covered Person receives treatment or service for a Pre-Existing Condition, the Company: a) will not pay benefits for such condition until the day after a 12 consecutive month period has passed from the Covered Person s effective date; and b) will pay only for loss or expense incurred after such 12 consecutive month period. If a Covered Person becomes insured under this Plan and was covered under Creditable Coverage, the Company will credit the time the Covered Person was covered under prior Creditable Coverage in determining whether the exclusion for a Pre-Existing Condition applies. A period of Creditable Coverage will be credited if the previous Creditable Coverage was continuous to a date not more than 63 days prior to the Effective Date of the new coverage. Payment will be in accord with the provisions of the Policy. If the Covered Person has a lapse in coverage, the Pre-Existing Condition waiting period will have to be satisfied again. The Pre-Existing Condition Limitation does not apply to genetic information, in the absence of a diagnosis of a condition related to such information. Creditable Coverage Creditable Coverage means an individual, group or blanket policy, contract or program, that arranges or provides medical, hospital, and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage, as well as the following: 1. An employee group health plan; 2. A student blanket accident and sickness policy; 3. Health insurance or Health Maintenance Organization coverage; 4. Medicare; 5. Medicaid; 6. Chapter 55 of title 10, United States Code (CHAMPUS); 7. A medical care program of the Indian Health Services or of a tribal organization; 8. A state health benefits risk pool; 9. A health plan offered under the Federal Employee Health Benefits Program; 10. A public health plan as defined under Federal regulations; 11. A health benefit plan under Section 5(e) of the Peace Corps Act; and 12. Any other similar coverage permitted under State or Federal law or regulations. 4 5

5 Coordination of Benefits Benefits under the Policy are coordinated according to the provisions of Rule 74 of the Idaho Department of Insurance regarding Coordination of Benefits. Coordination of Benefits means the order in which claims are paid. Coordination permits secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses. Definitions Covered Person means a person: 1) who is eligible for coverage as the insured student or as a dependent; and 2) who has been accepted for coverage or has been automatically added; and 3) who has paid the required premium; and 4) whose coverage has become effective and has not terminated. Hospital Confined/Hospital Confinement means confinement in a hospital for at least 18 consecutive hours for which a room and board charge is made by reason of a Sickness or Injury for which benefits are payable. Injury means bodily injury caused by an accident which is the sole cause of the loss. All injuries due to the same or a related cause are considered one Injury. Medically Necessary means a service, drug or supply needed for the diagnosis or treatment of an Injury or Sickness in accordance with generally accepted standards of medical practice in the United States at the time the service, drug or supply is provided. A service, drug or supply shall be considered needed if it: 1) is ordered by a licensed Doctor; and 2) is commonly and customarily recognized through the medical profession as appropriate for the particular Injury or Sickness for which it was ordered. A service, drug or supply shall not be considered as Medically Necessary if it is investigational, experimental, or educational. Reasonable and Customary (R&C) Expenses means fees and prices generally charged within the locality where performed for Medically Necessary services and supplies required for treatment of cases of comparable severity and nature. Reasonable and Customary Expenses are determined by referencing the 75th percentile of the most current survey published by Ingenix for such services or supplies. Sickness means an illness or disease which is the sole cause of the loss. All sicknesses due to the same or a related cause are considered one Sickness. Sickness includes pregnancy and complications of pregnancy. Total Disability/Totally Disabled means, with respect to the insured student, the complete inability to perform all of the substantial and material duties of his or her occupation and any other gainful occupation in which such person earns substantially the same compensation earned prior to disability. With respect to a covered dependent, Hospital Confinement. Claim Procedure Obtain a claim form from the Student Health Service or by visiting fill in the necessary information, attach all itemized doctor and hospital bills and send to: Personal Insurance Administrators, Inc. P.O. Box 6040 Agoura Hills, CA Please note that prescriptions will need to be paid for in full by the Covered Person at the time of purchase. The Covered Person may then submit a claim for reimbursement of the portion the Company is responsible for paying. The completed claim form and all hospital and medical bills must be submitted for payment within 90 days after the date loss occurs. Failure to furnish this information within the 90-day period shall not invalidate nor reduce your claim if it was not reasonably possible to file the claim within this time, provided that the claim form is submitted as soon as is reasonably possible. In no event, except in the absence of legal capacity, will a claim be honored later than one (1) year from the date of first medical Treatment. In the event it becomes necessary to check on the status of a filed claim, call the Claims office from 8:00 a.m. to 4:30 p.m. (Pacific Time), Monday through Friday at You have the right to request an independent medical review if health care services have been improperly denied, modified, or delayed based on Medical Necessity. Always keep a copy for your files of all forms submitted for claims. 6 7

6 Medical Benefits Schedule When a covered Injury or Sickness requires treatment by a physician, the Policy will provide benefits for 52 weeks from the date of Injury or the date of first treatment of a Sickness, for covered charges up to the Reasonable and Customary (R&C) Expenses scheduled below. BASIC INJURY BENEFITS $1,500 maximum PER each Injury, subject to the following limits: Hospital Room and Board Dental Treatment (repair and/or replacement of sound, natural teeth) Motor Vehicle Injury All Other Covered Services BASIC SICKNESS BENEFITS $1,500 maximum PER each Sickness, subject to the following limits: Hospital Room and Board Hospital Intensive Care Hospital Miscellaneous Inpatient (for x-ray examination, laboratory tests, anesthesia, operating room, medications, dressings, etc.) Nurse Expense Hospital Outpatient Surgical Miscellaneous (in lieu of Inpatient) Surgical Treatment (in or out of hospital, services performed by a licensed physician as determined by reference to the 75th percentile of the most current survey published by Ingenix Inpatient Physician Visit (Non-surgical) Outpatient Physician Visit (Non-surgical) Outpatient Diagnostic, X-ray and Lab Services and Hospital Emergency Room (Outpatient) Mental and Nervous Disorders / Substance Abuse Treatment semi-private room rate 8 9 $250 same as any Injury R&C semi-private room rate semi-private room rate $750 up to $12 per day $750 $750 $15 per visit, 1 visit per day $15 per visit, 1 visit per day, starts with 3rd visit for each Sickness aggregate limit up to $75 same as any Sickness Ambulance Services $33 Outpatient Prescription Drugs Prescriptions will need to be paid for in full at the time of purchase. The Covered Person may then submit a claim for reimbursement of the portion the company is responsible for paying Maternity Benefits paid under Major Medical same as any Sickness Maternity expense and routine newborn care, including up to 48 hours hospital confinement following vaginal delivery and 96 hours for caesarean delivery. If admission to the hospital occurs after delivery, the time period begins at the time of admission. Covered services include charges by a certified nurse-midwife under qualified medical direction if he or she is affiliated with or practicing in conjunction with a licensed facility. Breast Reconstruction Following Mastectomy same as any Sickness Includes reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses (e.g. breast implant) and treatment for physical complications of the mastectomy, including lymphedema. Mammograms a) one (1) between the ages of 35 through 39; b) one (1) every two (2) years for ages of 40 through 49; c) one (1) every year over the age of 50; and d) for any woman desiring a mammogram for medical cause. MAJOR MEDICAL BENEFITS $11,500 Maximum Benefit for Each Injury or Sickness After the Company has paid the Maximum Benefit of $1,500 under the Basic Benefits, the Company will then pay 80% of the Reasonable and Customary Expenses for covered charges up to the Lifetime Aggregate Maximum Benefit of $11,500 for each Injury or Sickness. This Maximum includes the amount paid under the Basic Injury or Basic Sickness Benefits. No benefits are payable under the Major Medical Benefit for dental treatment in excess of $600 or for mental and nervous disorders and substance abuse.

7 Certification of Qualifying Health Plan Coverage If a Covered Person is no longer eligible to be insured under the plan, the Covered Person should request a Certification of Qualifying Health Plan Coverage from Renaissance Agencies, Inc. This request can be made by phone or in writing. This request must include the name of the school and the name of each person who is no longer eligible to be insured under the plan. Authorized Representation In accordance with state and federal rules and regulations, we will not disclose individual information without authorization. This includes disclosures to family members for insured individuals who have reached the age of majority. If the Covered Person would like to authorize an additional party to act as a personal representative for matters pertaining to this insurance plan, we must have an Authorization Form on file. To request a form, please contact Renaissance Agencies, Inc. at the address below or complete a form via the internet at: Summary of Privacy Policy We strongly believe in maintaining the confidentiality of the personal information we obtain and/or receive about Covered Persons and we are committed to protecting the privacy of Covered Persons. We do not disclose any nonpublic information about Covered Persons to anyone, except as permitted or required by law. We do not sell or otherwise disclose Covered Person s personal information to anyone for purposes unrelated to our products and services. We maintain physical, electronic and procedural safeguards that comply with federal and state regulations to protect information about Covered Persons from unauthorized disclosure. We may disclose any information we believe necessary to conduct our business as is legally required. Covered Persons have the right to access, review and correct all personal information collected. Covered Persons may review this Privacy Policy in its entirety, or the Privacy Policies of other entities servicing the Policy, by writing to the address or visiting the website shown below. Covered Persons may also submit a request, in writing, to review your information at the address below. Attention: Privacy Manager Renaissance Agencies, Inc. P.O. Box 2300 Santa Monica, CA Phone: Facsimile: Website: Nationwide Life HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of this Notice of Privacy Practices apply to Nationwide Life Insurance Company, National Casualty Company, and the area within Nationwide Mutual Insurance Company that performs healthcare functions. In this Notice, Nationwide Life or We means the healthcare functions of Nationwide Life Insurance Company, which is a hybrid covered entity. the healthcare functions of National Casualty Company, and Nationwide Mutual Insurance Company, a business associate As permitted by law, Nationwide Life will share protected health information (PHI) of members as necessary to carry out treatment, payment, and healthcare operations. We are required by HIPAA and certain state laws to maintain the privacy of our members PHI and to provide members with notice of our legal duties and privacy practices with respect to their PHI. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all PHI maintained by us. Copies of the revised notices will be mailed to all current plan members or insureds. Protected health information (PHI) that is the subject of this Notice is information that is created or received by Nationwide; and relates to the past, present, or future physical or mental health or condition of a member; the provision of health care to a member; or the past, present, or future payment for the provision of health care to a member; and that identifies the member or for which there is a reasonable basis to believe the information can be used to identify the member. It includes information of persons living or deceased. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION Your Authorization. Except as outlined below, we will not use or disclose your PHI for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing, unless we have taken any action in reliance on the authorization. Other Uses and Disclosures. We are permitted or required by law to make certain other uses and disclosures of your PHI without your authorization. We may release your PHI for any purpose required by law. This may include releasing your PHI to law enforcement agencies; public health agencies; government oversight agencies; workers compensation; for government audits, investigations, or civil or criminal proceedings; for (continued on page 12) 10 11

8 HIPAA NOTICE (continued from page 11) approved research programs; when ordered by a court or administrative agency; to the armed forces if you are a member of the military; and other similar disclosures we are required by law to make. We may release your PHI to your plan sponsor, provided your plan sponsor certifies that the information provided will be maintained in a confidential manner and not used in any other manner not permitted by law. OTHER PRIVACY LAWS AND REGULATIONS Certain other state and federal privacy laws and regulations may further restrict access to and uses and disclosures of your personal health information or provide you with additional rights to manage such information. If you have questions regarding these rights, please send a written request to your designated contact. Access to Your Protected Health Information. You have the right to copy and/or inspect much of the PHI that we retain on your behalf. All requests for access must be made in writing and signed by you or your personal representative. We may charge you a fee if you request a copy of the information. The amount of the fee will be indicated on the request form. A request form can be obtained by writing your designated contact. Amendments to Your Protected Health Information. You have the right to request that the PHI that we maintain about you be amended or corrected. We are not obligated to make all requested Amendments but will give each request careful consideration. If the information is incorrect or incomplete and we decide to make an amendment or correction, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. A request form can be obtained by writing to your designated contact. Accounting for Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures made by us of your PHI. Requests must be made in writing and signed by you or your personal representative. A request form can be obtained by writing your designated contact. Disclosures for Treatment, Payment and Health Care Operations. We will make disclosures of your PHI as necessary for your treatment, payment, and/or health care operations. For instance, for your Treatment, a doctor or health facility involved in your care may request information we hold in order to make decisions about your care. For Payment, we may disclose your PHI to our pharmacy benefit manager for administration of your prescription drug benefit. For Health Care Operations, we will use and disclose your PHI as necessary, and as permitted by law, for our health care operations, which include responding to customer inquiries regarding benefits and claims. (continued on page 13) HIPAA NOTICE (continued from page 12) Family and Friends Involved In Your Care. With your approval, we may from time to time disclose your PHI to designated family, friends, and others who are involved in your care or in payment for your care in order to facilitate that person s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited PHI with such individuals without your approval. Business Associates. Certain aspects and components of our services are performed through contracts with outside persons or organizations. At times it may be necessary for us to provide some of your PHI to one or more of these outside persons or organizations. In all cases, we require these business associates by contract to appropriately safeguard the privacy of your information. Other Health-Related Products or Services. We may, from time to time, use your PHI to determine whether you might be interested in or benefit from treatment alternatives or other health-related programs, products, or services which may be available to you as a member of the health plan. For example, we may use your PHI to identify whether you have a particular illness, and advise you that a disease management program to help you manage your illness better is available to you. We will not use your information to communicate with you about products or services which are not health-related without your written permission. Information Received Pre-enrollment. We may request and receive from you and your health care providers PHI either prior to your enrollment in the health plan or the issuance of your policy. We will use this information to determine whether you are eligible to enroll in the health plan and to determine your rates. We will protect the confidentiality of that information in the same manner as all other PHI we maintain and, if you do not enroll in the health plan we will not use or disclose the information about you we obtained without your authorization. tcommunications With You. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your PHI information from us by alternative means or at alternative locations. A request form can be obtained by writing your designated contact. Complaints. If you believe your privacy rights have been violated, you can file a written complaint with your designated contact as explained in the Contact Information section, below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights, in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint. (continued on page 14) 12 13

9 HIPAA NOTICE (continued from page 13) CONTACT INFORMATION If you have any questions about this statement, need copies of any forms or require further assistance with any of the rights explained above, contact us by calling , or mail your request to: Privacy Officer PIA, Inc Agoura Road, Suite 250 Agoura Hills, CA As a member, you retain the right to obtain a paper copy of this Notice of Privacy Practices, even if you have requested such copy by or other electronic means. EFFECTIVE DATE This Nationwide Life HIPAA Notice of Privacy Practices is effective April 14, NATIONWIDE LIFE INSURANCE COMPANY POLICY NO Enrollment Form EASTERN IDAHO TECHNICAL COLLEGE STUDENT HEALTH INSURANCE PLAN DEPENDENT ENROLLMENT FORM For use only for dependents of students insured under this plan. 1. PLEASE PRINT CLEARLY STUDENT S LAST NAME STUDENT S FIRST NAME INITIAL STUDENT S PERMANENT MAILING ADDRESS STREET APT/BOX # CITY STATE ZIP STUDENT S PHONE NUMBER STUDENT S DATE OF BIRTH (MM/DD/YY) STUDENT S SOCIAL SECURITY NO. STUDENT ID NUMBER q MALE q FEMALE STUDENT S ADDRESS For questions regarding benefits or claims: Personal Insurance Administrators, Inc. P.O. Box 6040 Agoura Hills, CA Toll Free: For questions regarding eligibility or enrollment, contact the Servicing Agent: Renaissance Agencies, Inc. P.O. Box 2300 Santa Monica, CA To download brochures or claim forms: 2. Mark the TERM IN WHICH YOU ARE ENROLLING FALL TERM (08/18/08 to 01/12/09) SPRING TERM (01/12/09 to 05/18/09) SUMMER TERM (05/18/09 to 08/24/09) 3. INDICATE PREMIUM AMOUNT PAID EACH ADDITIONAL DEPENDENT $89.00 NUMBER OF DEPENDENTS TO BE ENROLLED x TOTAL PREMIUM DUE = 4. LIST DEPENDENTS TO BE INSURED ON the reverse side of this form 5. Make check or money order payable to: NATIONWIDE LIFE INSURANCE COMPANY 6. Return payment with enrollment form to: Renaissance Agencies, Inc. P.O. Box 2300 Santa Monica, CA STUDENT MUST sign FORM BELOW I understand that dependent coverage becomes effective only when this enrollment form and full premium payment are received by Renaissance Agencies, Inc., according to the terms and conditions listed IN THE brochure. Student s Signature Date Signed 14 EITC/EF

10 STUDENT S SIGNATURE DATE SIGNED CHILD M F CHILD M F CHILD M F SPOUSE M F LAST NAME FIRST NAME MI DATE OF BIRTH SOCIAL SECURITY SEX (MM/DD/YY) NUMBER Dependent coverage is available only if the student is also insured under this plan. List Dependents to be insured below. Notice: Underwritten by: Nationwide Life Insurance Company Policy Number: This brochure describes your benefits under the plan of insurance sponsored by your school. It is not a contract of insurance. Your coverage is governed by a policy of blanket injury and sickness insurance underwritten by the Nationwide Life Insurance Company. As evidence of your coverage, a policy of insurance (Policy Number ) has been issued to your school which contains the benefits and provisions which apply to the plan of insurance sponsored by your school. Any discrepancy between this brochure and the policy will be governed by the policy. Please keep this brochure for future reference. ID Card ID CARD please detach and retain no other will be issued Underwritten by: NATIONWIDE LIFE INSURANCE COMPANY Policy No Insured EASTERN IDAHO TECHNICAL COLLEGE STUDENT INSURANCE PLAN Both the effective and termination dates of coverage are subject to verification by the Company. (Address on reverse side)

11 For questions regarding claims and coverage, contact: Personal INSURANCE ADMINISTRATORS, INC. P.O. Box 6040 Agoura Hills, CA Toll Free Note: Benefits are subject to payment of appropriate premium and verification of eligibility.