1 United I.S.D. Student Extra-Curricular Insurance Sponsor Kit
2 Sponsor Kit (Student Extra-Curricular Insurance) The following forms make up the sponsor kit for extra-curricular activities. Attached you will find: 1. Memo listing covered activities. 2. English and Spanish Parent Notification and Acknowledgment forms a. Parents must sign form prior to participation. b. 1 copy stays with parent and 1 copy is returned to sponsor for filing. 3. Accident Procedures Form a. Step by step procedures. 4. How To File A Claim Information Form 5. Claim Form a. Part #1 needs to be filled out by you the coach/sponsor. b. Fax a copy of the claim form along with a copy of the Parent Notification and Acknowledgment form signed by the parent at the beginning of the season to Risk Management and then save a copy in your files. c. Refer parent to Risk Management for assistance in filing claim ( ). 6. Schedule of Benefits a. Explanation of payable benefits. Parents are responsible for balances. **************************************************************** Plan Hightlights A. Plan covers injuries sustained by students in the direct pursuit of the primary extracurricular activity i.e. district directed practice, competition events, etc Plan DOES NOT cover unrelated events such as regular class activities, fund raisers, or fun field trips. B. Plan is secondary to any plan parents may have. C. Plan coverage is limited. Parents are responsible for balances. D. Treatment must begin within 30 days of the injury. (Sponsor must fax initial claim and parent acknowledgment form to Risk Management ASAP.) E. Claim must be filed within 90 days of the injury. F. Treatments must be completed within 12 months of injury. For further information please contact the Risk Management Department at PS The Administrator On Call (AOC) cell number is This number is manned by an administrator with the authority of the Superintendent to make decisions in emergency situations. Please take this cell number with you when you travel out of town with your students. Use it in the event of an emergency.
3 Robert Chapa Director of Risk Management Date: August 1, 2010 To: RE: Middle and High School Student Extra-Curricular Activity Sponsors And Elementary School Cheerleader and Dance Sponsors Extra-Curricular Activities Student Insurance The District annually purchases Extra-Curricular Activities Student Insurance to cover medical costs for accidents occurring during extra-curricular activities at High Schools and Middle Schools and for Cheerleading and Dance programs at the elementary schools. Covered activities include practices, special events, and related out of town activities. The following is a listing of covered extra-curricular organizations, clubs, and disciplines: ALL SPORTS (Middle and High School Only) Football Volleyball Cross-Country Track Tennis Basketball Baseball Softball Golf Swimming Soccer Special Olympics ALL OTHER(Middle and High School Only) Cheerleaders Band Drill Team Pep Squad Choir Drama FFA ROTC Special ED. Co-op UIL Academics Health Occupations Practicum Technology Academy Co-op Elementary Schools Only Cheerleader and Dance Programs The Student Extra-Curricular Student Insurance is a secondary plan to all other plans covering students including parent s coverage. All questions concerning this insurance should be directed to the Risk Management Department at Lindenwood Dr. Laredo, TX (956) Fax (956)
4 Robert Chapa Director of Risk Management To: From: Subject: Parents or Guardians of All Students Who Participate in Athletics and Extracurricular Sponsored Activities Robert Chapa -- Risk Management Dept. Extracurricular Student Insurance Date: August 1, 2010 The following facts should be fully understood by the parents and guardians of all United Independent School District athletes and students who participate in U.I.L. and extracurricular activities. 1. The United Independent School District carries accident insurance for students involved in school sponsored athletic and extracurricular activities. Your child will be covered while participating in, practicing for, and traveling to and from such an activity. Injuries occurring during regular class activities are NOT covered. 2. The insurance provided by the school is for activities that are sanctioned by U.I.L. rules and regulations and sponsored by the district. Accidents occurring during activities not directly related to the primary activity are not covered, i.e. fundraisers, car washes, etc United Independent assumes no responsibility as a result of injuries that occur during an athletic or U.I.L. event, however, this insurance is provided at school expense. This is SECONDARY INSURANCE to whatever health insurance the parent or guardian has for their children, and all claims should be filed first with the parent s primary health insurance company, second with the district insurance Co. You will need to indicate on the Student Insurance claim form the name and address of your primary insurance carrier. 4. Since this coverage is secondary, the insurance carrier will pay only after they have received information from the primary health carrier as to how much of the claim was not paid. 5. If the student has no other insurance coverage the district plan will become the primary plan and will pay accordingly. The parent or guardian should indicate on the claim form if they have no other insurance.
5 6. All policies have limitations. The district plan will only pay up to certain amounts that are listed in the schedule of benefits. (See Attached) Parents will be responsible for any additional amounts. 7. The United Independent School District and its employees are NOT responsible for any costs, treatments, or insurance claims for your child. 8. In case of an injury, it is the parent s responsibility to file a claim within 90 days of the injury. Claim forms are available in the principal s office, from the trainer, coach, sponsor, or the District Risk Management Office located at 201 Lindenwood. The coaches, trainers, sponsors or administrative personnel will be happy to assist you in completing the claim form, however, United Independent School District employees are not responsible for filing claims. 9. As with any insurance, there are policy limitations. Please review carefully the schedule of benefits. (See Attached) 10. Treatment must begin within 30 days from the injury and claims must be filed within 90 days of the first treatment. If you have any questions, please feel free to call the District Risk Management office at , or ask your sponsor or coach I have read and understood that the coverage provided by United Independent School District has certain limitations and is considered secondary to all other health insurance s we may have. I further understand that United Independent School District is not responsible for filing claims or for payment of any medical expenses related to extra-curricular activities. Student s Name School Signature of Parent or Guardian Date 201 Lindenwood Dr. Laredo, TX (956) Fax (956)
6 Robert Chapa Director of Risk Management A: Los padres y Tutores de Todos los Estudiantes Quien Participan en el Atletismo y Actividades Extracurriculares patrocinadas De: Sujeto: Sr. Roberto Chapa -- Departamento de Riesgo Aseguranza para estudiantes que participan en Actividades Extracurriculares Fecha: 1 de Agosto de 2010 Los hechos siguientes deberan ser totalmente entendidos por los padres y los tutores de todos los atletas y estudiantes que participan en las actividades de U.I.L. y algunas otras actividades extracurriculares del Districto Independiente de United. 1. El Districto Independiente de United mantiene aseguranza para accidents de estudiantes participando en actividades extracurriculares. Su hijo(a) sera asegurado(a) por esta aseguranza mientras que este participando en, participando para, y viajando a y desde tal actividad. 2. La aseguranza proporcionada por la escuela son para actividades que son sancionadas por las reglas y regulaciones de U.I.L. Todos los accidentes que ocurran durante las actividades no relacionadas directamente a la actividad primaria no seran cubridas, i.e. classe regular, levantar fondos, lavar carros, etc El Districto Independiente de United no asume responsabilidad como resultado de danos o lastimaduras que ocurren durante eventos atleticos o U.I.L. sin embargo, el seguro se provee el costo de la escuela. Este es SEGURO SECUNDARIO a cualquier otro seguro de los padres. Todos los reclamos deberan archivarse primero con la compania de seguros de los padres y despues con la aseguranza del districto. Usted necesitaria indicar sobre el reclamo el nombre y direccion de cualquier otra aseguranza que pertenecen. 4. Como este seguro es secundario, el seguro del districto pagara unicamente despues de que ellos reciban informacion de el transportador primario de salud con respecto a la cantidad del reclamo que sera pagado por ellos.
7 5. Si el estudiante no esta protejido por otro seguro, entonces el seguro del districto llegara a ser el transportador primario y pagara consiguientemente. El padre o el tutor debe indicar en el reclamo si ellos no tienen otro seguro de salud. 6. Todas las polizas tienen limitaciones. La aseguranza del districto pagara hasta las cantidades que se enumeran en el folleto del estudiante. (Vea Adjunto) Los padres seran responsables por cualquier cantidad que permanezca despues de que su seguro primario o el suguro del districto haya llegado a sus limitaciones. 7. El Districto Independiente de United y sus empleados NO se hacen responsables de ningun gasto, tratamientos, o reclamos de su hijo(a). 8. En el caso de un dano o lastimadura, es la responsabilidad del padre para archivar una forma de reclamo. Estas formas son disponibles en la oficina del director de la escuela, con los entrenadores, en la oficina Atletica, o en la oficina del Departamento de Riesgo que esta ubicada en la calle 201 Lindenwood. Los entrenadores, los patrocinantes o el personal administrativo puede ayudarle a completar la forma, sin embargo, ningun empleado del Districto Independiente de United sera responsable para archivar su reclamo. 9. Como con cualquier poliza, hay exclusiones. Favor de revisar las limitaciones de la poliza que se enumeran. (Vea Adjunto) 10. El tratamiento debe comenzar dentro de los primeros 30 dias de haber ocurrido el dano o lastimadura y el reclamo debe archivarse dentro de 90 dias del primer tratamiento. Si usted tiene cualquier pregunta, favor de llamar al , o preguntarle a su patrocinante o entrenador Yo he leido y comprendido que la proteccion proveida por el Districto Independiente de United tiene ciertas limitaciones y se considera proteccion primaria unica si yo no tengo otra aseguranza para mi hijo(a). Yo comprendo que el Districto de United no es responsable por el relcamo de seguro o el pago de ningun gasto medico. Nombre del Estudiante Firma Del Padre o Tutor Escuela Date 201 Lindenwood Dr. Laredo, TX (956) Fax (956)
8 United Independent School District STUDENT EXTRACURRICULAR INSURANCE ACCIDENT PROCEDURES As a sponsor of a student activity, you are entrusted with the safety of all the students in your organization. The following procedures will aid in ensuring that you, the student, and the parents will have a minimum of problems in reporting and settling accident claims. In the event of a student accident while in the pursuit of an extra-curricular activity the following information should be used as a guide: 1. Assess the situation to determine the severity of the accident. For Major Injury 2. Contact the parents immediately to inform them of the situation. If the situation permits, ask parents for their preference of hospitals. Parents health insurance network providers should be considered first as their insurance coverage is primary. If parents have no health insurance coverage, then the extra-curricular network providers should be utilized, if available. 3. If needed, call 911 to obtain an ambulance to transport the student to the closest hospital or transport the student in the safest and quickest way possible. 4. Upon checking in, provide the hospital or physician with the name and address of the child s parents, if known, if not, refer them to the UISD Risk Management Department at (956) Obtain paperwork/receipts documenting the hospital or physician visit and forward to Risk Management Department. For Minor Injury 6. Fill out the School and Student Information section of the Accident Claim Form and provide a copy to childs parents. Fax a copy of the claim form along with a copy of the Parent Notification and Acknowledgment form signed by the parent at the beginning of the season to the Risk Management Department ( fax). Make a copy of the Accident Claim form for your files. 7. Provide the parents of the student with a copy of the Accident Claim Form and the related paperwork/receipts and refer them to the Risk Management Department for management of the case. Advise parents that our insurance will only cover eligible expenses for medical services provided within 30 days of the injury and for claims submitted within 90 days of the treatment. 8/1/10
9 Mail completed form to: STUDENT ASSURANCE SERVICES. INC. P.O. BOX 196 STILLWATER. MINNESOTA e~ '--... A Provider Selection ': ~ 800-USA 3860 rftrra H&W Network Be sure to use the services of a USA MCO provider to receive discounts for services provided by physicians and facilities participating in the USA MCO Network. This plan is supplemental to all other insurance coverage. You must file a claim with your other insurance first. PROOF OF CLAIM: When Injury results in treatment by a Physician, complete this form and submit to Student Assurance Services, Inc. within 90 days from date of injury. PART A: NOTICE OF INJURY 1. Name of School School District Name _ School Address ~rr.:_;_ r=_;:;r_----7"jt":;:; --- (city) (State) (Zip) 2. Name of Insured Grade _ 3. Date of Injury DAM DPM 4. Under whose supervision? Was he/she a witness? _ 5. The accident was incurred while the Insured was participating in: INTERSCHOLASTIC UIL ACTIVITY NON-INTERSCHOLASTIC UILACTIVITY ) Practice What sport/activity? )Travelto/fromschool ( ) Non-school activity ) Game/Event ) In classroom () Other - Activity? ) Travel ) Physical Education ) On school grounds 6. Part of the body injured _ DR side DL side 7. Describe in detail how and where the injury occurred _ Reported by (Signature of School Official) (Title) (Date) ("Part A may be completed by the parent if Full-Time Co\terage was purchased.) IMPORTANT IN FORMATION ON REVERSE SIDE _ PART B: PARENT STATEMENT 1. Students Name --====---===--===== Birthdate _ Students Social Security #-rn-ITLD Parents Name Relationship to Insured _ Address ---:-::---:----::- :_-: :-=-: :_ :-: (Street or Route) (City) (State) (Zip) 2. Home phone number _ 3. Father's Occupation Employer _ Mother's Occupation 4. List your family or group coverage, please. Employer_ Name of Insurance Company _ DGroup Dlndividual DPolicyNo Address ~---:: :-::-;-~ ~ = :_--- (Street) (City) (State) (Zip) Ihereby authorize any physician, medical practitioner, hospital, clinic, othermedical or medically related facility, insurance company, or other organization, institution, or person that has any records or knowledge ofthe claimants physical or mental health, to give the information to STUDENT ASSURANCE SERVICES, INC. To facilitate rapid submission of such information, I authorize all said sources, to give such records or knowledge to any agency employed by the insurance company to collect and transmit such information. Aphotocopy ofthis authorization shall be as valid as the original. This authorization expires one yearfrom the date signed. (Date) (Print Name of Student/Patient) (Signature of Parent or Guardian) NOTICE: Anyone who knowingly misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine or im risonment. Form CLM-2 (07)TX
10 ATTENTIONPARENTS ****PARENTS "YOU'RE RESPONSIBLE"**** Dear Parents, Below are steps for completing the Claim Form Should you have any questions, contact the school trainer or call the number listed on the claim form. The school "IS NOT" responsible for your medical payment or bills for your child. If your child is injured during ANY Athletic or UIL sponsored event or activity all medical charges are "YOUR RESPONSIBILITY." HOWEVER, the school may have purchased a supplemental policy to cover any charges in excess of your own insurance polley. If you have NO OTHER INSURANCE for your child, this policy will then pay first or primary. This is a limited benefit policy and any charges above policy benefit limits are YOUR RESPONSIBILITY. This policy was purchased by the district based on funds available. Please be aware that this is a limited benefit policy and by NO MEANS was it Intended to cover all medical bills for your child. Your child's treatments and medical charges are your responsibility. Please contact the school trainer or administrator before seeking medical treatment or services. STEPS TO FOLLOW WHEN FILING A CLAIM: 1. A school official must complete Part A for all school related accidents. The parent or guardian must complete all questions In Part B Parent Statement. If the accident is not school related, parent or guardian may complete Part A. This Claim Form must be presented tothe physician orfaclllty In orderto obtainthe USAMCO ProviderDiscount. Do not leavethe claim form with the provider orfacility. Complete and submit directly to the Claim's Office at the address indicated below. 2. Send copies of Itemized bills. These are the original billings you receive, not monthly statements. These itemized bills often called UB92 or HCFA 1500 provide the Address, Procedure Code, Diagnosis Code, and the Provider's Tax 10 Number. 3. Submit copies of all bills to your family and/or group insurance, even if you have a large deductible. This plan is supplemental to all other valid coverage. You must file a claim with your other insurance first. This plan does not cover penalties imposed for failure to use providers preferred or designated by your primary coverage. After you have received payment or copies of "Explanation of Benefits" (EOB) from your family insurance company or insurance administrator (Blue Cross, Group Health, Prudential Insurance, etc.), send our claim form, copies of itemized bills and your other insurance E.O.B.'s to: STUDENT ASSURANCE SERVICES, INC. P.O. BOX 196 STILLWATER, MN NO CLAIM CAN BE PROCESSED UNTIL ALL OF THE ABOVE DOCUMENTS ARE PROVIDED. PREFERRED PROVIDER DISCOUNT PROGRAM Student Assurance Services, Inc. has contracted for discounts for services received from physicians and facilities participating in the USA Manged Care Organization Network. Please note that benefits are payable as described whether you use a participating provider or not. However, it is to your advantage to use a participating provider since your costs will be reduced. A listing of participating physicians and facilities are available at the USA MCO Network website PLEASE REFER TO THE MASTER POLICY ISSUED TO THE SCHOOUSCHOOL DISTRICT FOR SPECIFIC DETAILS.
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