ENROLLMENT FORM - STUDENT ACCIDENT INSURANCE School Year

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Rhoda Shelton
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1 ENROLLMENT FORM - STUDENT ACCIDENT INSURANCE School Year ENROLLMENT INSTRUCTIONS Fill out this enrollment form completely. Make your check or money order payable to Cabot Risk Strategies LLC. Be sure to write your child s name on the check. DO NOT send cash. Place this form and your payment into an envelope and mail to the address below. Keep your cancelled check or money order receipt as proof of payment. Keep the summary document in your records as a description of coverage. Print and keep the Student Insurance ID Card. School System: School Name: Student Full Name: Parent Full Name: Student Date of Birth (mo/day/year) / / Sex: M F Student Home Phone: ( ) Student Address: Street City State Zip PLAN SELECTION Check one: Annual Premium 24 Hour Wrap Around Coverage $ Hour Wrap Around Coverage + School Time Dental 24 Wrap Around Coverage + Accidental Dental Make check or money order payable to: Cabot Risk Strategies LLC Amount Enclosed: Check or money order number: $55.00 $58.00 Mail to: Cabot Risk Strategies LLC 15 Cabot Road Woburn, MA Signature of Parent/Guardian: Date: ph: fax: Rev.4 05/18

ATTENTION PARENTS AND GUARDIANS: ACCIDENT INSURANCE PROTECTION FOR STUDENTS www.cabotrisk.

2 ATTENTION PARENTS AND GUARDIANS: ACCIDENT INSURANCE PROTECTION FOR STUDENTS Delivering adequate insurance coverage for your child in the event of an unforeseen accident Your child s school offers the following insurance products on a voluntary basis: $500,000 At School Student Accident Coverage $500,000 Around the Clock 24 Hour Accident Coverage $50,000 Student Accident Dental Coverage Voluntary Rates 24 Hour Wrap Around Coverage: $ Hour Wrap Around Coverage + School Time Dental: $ Hour Wrap Around Coverage + 24 Hour Accidental Dental: $58.00 Two Ways to Enroll: Online or By Mail PROTECTION PLUS, offered by & Cabot Risk Strategies LLC 15 Cabot Road Woburn, MA ph: fax: Rev.4 05/18

5 Protection when you need it most Cover your child against the unexpected, whether at home or at school Student Accident Insurance

6 Summary of Benefits and Limitations Despite best efforts to protect them, children get hurt... sometimes seriously. Obtaining the care they need can be expensive. Your school has arranged for these valuable plans to assist you with the expense of unexpected emergencies. Accidental Medical Expense Benefit The plans provide benefits for a loss due to a covered Accidental Bodily Injury up to the maximum benefit as described below for each injury. Coverage is provided for those Accident Medical Expenses incurred within 104 weeks from the date of the original Accident. Treatment must begin within 60 days from the date of the Accident. Maximum Accident Medical $500,000 Policy Limit Motor Vehicle Accidents $10,000 maximum Hospital room and board expenses $500 per day Daily Intensive Care Unit/ Cardiac Care Unit Expenses $1,000 per day up to 5 days Ancillary Hospital expenses $500 maximum Physician non-surgical (inpatient) Physician surgical expenses Assistant Surgeon expenses 25% of Physician surgical Anesthesiologist expenses 25% of Physician surgical benefit Outpatient surgery expenses $500 maximum Physician non-surgical (outpatient) Physician Consultant Expense (outpatient) Physiotherapy (outpatient) Reasonable & Customary up to a maximum of $2,000 Ambulance expenses X-ray expenses (outpatient) Outpatient laboratory test expenses Diagnostic imaging expenses $500 Medical Emergency Care $500 Prescription drug expenses Outpatient registered nurse services Rehabilitative braces or appliances $2,000 maximum Dental expenses $500 per tooth maximum Deferred Dental Treatment (when certified by a dentist) $1,000 Eyeglasses, contact lenses $500 maximum and hearing aids Accidental Death and Dismemberment Benefits If, within 365 days from the date of a covered Accident, Accidental Bodily Injury to the Insured Person results in any of the Covered Losses shown below, We will pay the benefit in the amount set opposite such Loss. If multiple Losses occur, only one Benefit, the largest, will be paid for all Losses due to the same covered Accident. Loss of Life $10,000 Loss of Two or More Members $50,000 Loss of One Member $25,000 Loss of Thumb & Index Finger $2,500 of the Same Hand Loss of Four Fingers of $2,500 the Same Hand Member means Loss of Hand or Foot, Loss of Sight, Loss of Speech and Loss of Hearing. Loss of Hand or Foot means complete Severance through or above the wrist or ankle joint. Loss of Sight means the total, permanent Loss of Sight of one eye. Loss of Speech means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means. Loss of Hearing means total and permanent Loss of Hearing in both ears that is irrecoverable and cannot be corrected by any means. Definitions Accident means a sudden, unforeseen, an unexpected event which results in an Accidental Bodily Injury to the Insured Person. Accidental Bodily Injury means bodily Injury caused by the direct result of an Accident occurring while the Policy is in force as to the person whose Injury is the basis of the claim which results, directly and independently of all other causes, in a Covered Loss. Medically Necessary means a medical or dental service, supply or course of treatment which is ordered or prescribed by a Physician; is appropriate and consistent with the patient s diagnosis; is in accord with current accepted medical or dental practice; and could not be eliminated without adversely affecting the patient s condition. Reasonable and Customary Charges means the lesser of the usual charge made by Physicians or other health care providers for a given service or supply or the charge We reasonably determine to be the prevailing charge made by Physicians or other health care providers for a given service or supply in the geographical areas where it is furnished. 2

7 Important Facts 1. The Blanket Accident Policy on file with the school is a non-renewable, one-year term policy. 2. Effective Date Of Coverage: Insurance is effective on the latest of the following dates: the Policy Effective Date; the date the Insured Person is first eligible; the date We receive the completed enrollment form; or the date the required premium is paid. 3. Evidence Of Coverage: Verification of online payment and a copy of this brochure is your evidence of coverage under the School Sponsored Accident Policy. 4. Student Transfer: Coverage under the Policy continues in force anywhere in the world if the Insured Person should relocate prior to the expiration of coverage. 5. Cancellation: Coverage under the Policy will not be cancelled, and accordingly, premiums may not be refunded after acceptance by the Company. 6. Late Enrollment: There is no premium reduction for any individual who enrolls late in the year. Excess Provision As the result of an Accidental Bodily Injury, if an an Insured Person incurs Accidental Medical Expenses, the benefit amount will be paid subject to any other plan. The Benefit Amount is subject to the Coinsurance Percentage and Maximum Benefit Amount as shown in the Schedule of Benefits that are in EXCESS of expenses payable by any Other Plan. Parents/Guardians Why you should enroll now? Even if you have health insurance, benefits can help cover your deductible, copayment, and other out-ofpocket costs. No health questions asked everyone qualifies. Rates cannot increase during the year. Policy Exclusions Insurance does not apply to any Accident, Accidental Bodily Injury or Loss caused by or resulting from: 1. an insured person s emotional trauma, mental or physical illness, disease, pregnancy, childbirth or miscarriage, bacterial or viral infection, bodily malfunctions or medical or surgical treatment thereof. 2. an insured person s commission or attempted commission of any illegal act including but not limited to any felony. 3. an insured person being under the influence of any narcotic or other controlled substance at the time of the accident. This exclusion does not apply if any narcotic or other controlled substance is taken and used as prescribed by a physician. 4. an insured person being engaged in or participating in club, interscholastic or intramural sports. 5. an insured person being engaged in or participating in a motorized vehicular race or speed contest. 6. an insured person s participation in military action while in active military service with the armed forces of any country or established international authority. This exclusion does not apply to the first 31 days of active military service. 7. an insured person s suicide, attempted suicide or intentionally self-inflicted injury. 8. war. 9. an insured person being treated for a hernia whether or not caused by an accident. 10. an insured person being in, entering or exiting any aircraft while you are acting or training as a pilot or crew member. 11. any accident, accidental bodily injury or loss caused by or resulting from, directly or indirectly, from any injury where worker s compensation benefits or occupational injury benefits are payable. 12. any accident, accidental bodily injury or loss caused by or resulting from, directly or indirectly, an insured person s aggravation or re-injury of a prior injury that he or she suffered prior to his or her coverage effective date, unless written medical release from the insured person s physician is received. 13. any accident, accidental bodily injury or loss caused by or resulting from, directly or indirectly, while fighting, except in self-defense. 14. any accident, accidental bodily injury or loss caused by or resulting from, directly or indirectly, from treatment by a person employed or retained by the policyholder. Important Note: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. 3

8 Choose the Plan that is Right for you Annual Cost PLAN 1: 24-Hour Accident Only Coverage $48.00 Around the clock, anywhere in the world, 24 hours a day until one year after the date the Policy coverage begins. Annual Cost PlAN 2: School-Time Accident Only Coverage $7.00 Accident only plan that protects your student while on school premesis, during any school sponsored activity, traveling directly from home, school or school-sponsored activity, and while in a school in a school vehicle. How to File a Claim 1. Obtain a claim form from your school office and answer all questions in detail on the front of the claim form. 2. The claim form should identify the student s name, school name or district, and the date of accident. 3. Make sure the claim form is signed. 4. Attach all itemized bills to the completed claim form and mail to address provided on the claim form. 5. Bills that cannot be attached to the initial form must be submitted within 90 days of the date of service. Annual Cost OPTIONAL PLAN: Accident Only Dental Coverage $9.50 The Extended Dental Benefit can only be purchased if Plan 1 or Plan 2 have been elected and required premium is paid. Benefits not to exceed a maximum of $50,000 when injury to sound natural teeth requires treatment within 60 days of a covered Accident. IMPORTANT: This brochure is only a summary of your benefits under the accident plan of insurance sponsored by your school and is only a partial description of the entire insurance plan. It is not a contract of insurance. This brochure and its contents are intended to provide an overview of the insurance coverage provided under the Policy. Your coverage is governed by a policy of student accident insurance underwritten by U.S. based Chubb underwriting companies provided to your school. If there is a discrepancy between this brochure and the master Blanket policy, the master policy language will govern. A copy of the full Policy of insurance describing the benefits which are payable in accordance with the terms, conditions, and exclusions has been provided to your school and is available for viewing at your school s office. Please remember that only the complete Blanket Accident Insurance Policy can provide the actual terms of coverage and will govern and control the payment of benefits. Benefits described in the Policy will be paid in accordance with any applicable state law. IMPORTANT: Keep This Summary For Your Personal Records As A Description Of Coverage. Chubb is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services. For a list of these subsidiaries, please visit our website at Insurance provided by U.S. based Chubb underwriting companies. All products may not be available in all states. Coverage is subject to the language of the policies as actually issued. Surplus lines insurance sold only through licensed surplus lines producers.

Protection when you need it the most

STU DE NT ACCI DE NT I N S U RA NC E Protection when you need it the most Cover your child against medical and dental injuries, whether at home or at school Please keep this brochure as an outline of coverage