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 Highlights A. Plan covers injuries sustained by students in the direct pursuit of the primary extra-curricular activity i.e. District directed practice, competition, events, etc Plan DOES NOT cover unrelated events such as regular class activities, fund raisers, fun field trips or open gym. 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: July 14, 2014 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 Power Lifting 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: July 14, 2014 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. Check all activities in which participation is anticipated: FOOTBALL SOCCER - BOYS CHOIR VOLLEYBALL SOCCER - GIRLS CHEERLEADING SWIMMING BASEBALL DANCE TENNIS SOFTBALL R.O.T.C. GOLF POWER LIFTING U.I.L. ACADEMICS CROSS COUNTRY TRACK & FIELD - BOYS SPEECH & DEBATE BASKETBALL - BOYS TRACK & FIELD - GIRLS JOURNALISM BASKETBALL - GIRLS BAND - BAND, ORCHESTRA, MARIACHI, JAZZ, ETC ONE ACT PLAY 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 del Departamento de Gestión de Riesgos Para: De: Asunto: Padres o tutores de estudiantes que participen en deportes y actividades extracurriculares Roberto Chapa -- Departamento de Control de Riesgos Seguro para estudiantes que participen en actividades extracurriculares Fecha: 14 de julio de 2014 Los padres y tutores de deportistas y estudiantes que participan en U.I.L. y actividades extracurriculares de United Independent School District deben conocer la siguiente información. 1. United Independent School District cuenta con un seguro contra accidentes para los estudiantes que participen en actividades deportivas y extracurriculares patrocinadas por la escuela. Este seguro protegerá a su hijo mientras participe, entrene y durante el viaje de ida y vuelta a dicha actividad. Las lesiones que ocurran durante las actividades de clases regulares NO están amparadas por dicho seguro. 2. El seguro proporcionado por la escuela es para las actividades aprobadas por las normas y reglamentos de U.I.L. y por aquellas patrocinadas por el distrito. Los accidentes que ocurran durante las actividades que NO están relacionadas directamente con la actividad principal no están amparadas por dicho seguro. Por ejemplo, actividades para recaudar fondos, lavado de autos, etc 3. United Independent School District no asume la responsabilidad como resultado de las lesiones ocurridas durante un evento deportivo o de U.I.L.; sin embargo, este seguro se provee por cuenta de la escuela. Este es un SEGURO SECUNDARIO a cualquier seguro de gastos médicos que el padre o tutor tenga para sus hijos y todos los reclamos al seguro deben presentarse, en primer lugar, con la compañía de seguro de gastos médicos primaria del padre, y en segundo, con la compañía de seguros del distrito. Tiene que indicar en el formulario de reclamo del seguro del estudiante el nombre y la dirección de su proveedor de seguros primario. 4. Ya que la protección del seguro es secundaria, el proveedor de seguros pagará solamente después de haber recibido información del proveedor primario de seguros de gastos médicos para saber qué cantidad del reclamo no fue cubierta. 5. Si el estudiante no cuenta con ningún otro seguro, el plan de seguros del distrito se convertirá en el seguro primario y pagará según corresponda. El padre o tutor deben indicar en el formulario de reclamo si no cuentan con ningún otro seguro. 6. Todas las pólizas tienen restricciones. El plan del distrito solamente pagará cierta cantidad establecida en el plan de beneficios. (Ver anexo) Los padres serán responsables de cualquier cantidad adicional.
7 7. United Independent School District y sus empleados NO son responsables de ningún costo, tratamiento o reclamo al seguro de su hijo. 8. En caso de alguna lesión, es responsabilidad de los padres presentar el reclamo dentro de 90 días de ocurrida la lesión. Los formularios de reclamo están disponibles en la oficina del director escolar, instructor, entrenador, patrocinador o en la Oficina de Gestión de Riesgos del distrito, ubicada en 201 Lindenwood. Los entrenadores, instructores, patrocinados o personal administrativo con gusto le ayudarán a llenar dicho formulario; sin embargo, los empleados de United Independent School District no son responsables de presentar el reclamo. 9. Como cualquier seguro, existen restricciones en las pólizas. Favor de revisar cuidadosamente el plan de beneficios. (Ver anexo) 10. El tratamiento debe iniciar dentro de 30 días de ocurrida la lesión y los reclamos deben presentarse dentro de 90 días del primer tratamiento. Si tiene alguna pregunta, por favor no dude en contactar a la Oficina de Gestión de Riesgos del distrito llamando al o a su patrocinador o entrenador. Indique todas las actividades en las cuales participará: FÚTBOL FÚTBOL SOCCER - VARONIL CORO VOLEIBOL FÚTBOL SOCCER - FEMENIL PORRISTAS NATACIÓN BÉISBOL DANZA TENIS SOFTBALL R.O.T.C. GOLF LEVANTAMIENTO DE PESAS U.I.L. ACADÉMICO CAMPO TRAVIESA ATLETISMO - VARONIL DISCURSO Y DEBATE BASQUETBOL - VARONIL ATLETISMO - FEMENIL PERIODISMO BASQUETBOL - FEMENIL BANDA - BANDA, ORQUESTA, MARIACHI, JAZZ, ETC OBRA DE UN ACTO He leído y comprendo que la protección otorgada por el seguro de United Independent School District tiene algunas restricciones y que se considera como un seguro secundario a todos los demás seguros de gastos médicos que pueda yo tener. También comprendo que United Independent School District no es responsable de presentar los reclamos o de pagar ningún gasto médico relacionado con actividades extracurriculares. Nombre del estudiante Firma del padre o tutor Escuela Fecha 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 child s 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. 7/14/2014
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.
11 .' MEDICAL BENEFITS 0 When injury covered by this policy results in treatment by a Licensed Physician within 90 days from the date of injury, the Company will pay the USual and, Customary expenses incurred for necessary Services and Supplies as listed below, for expenses actually incurred within one year from the date of injury up to a Maximum Medical Benefit of $25,000 per injury, This policy will pay benefits only after all Other Valid and Collectible Coverage has been paid, A 1, 2, 3. IN-PATIENT BENEFITS 4, 5, Physical Therapy Treatment (includes whirlpool, diathenny. EMS, 6, 7, B. 1. C, OTHER OUT-PATIENT BENEFITS 1. Hospital Emergency Room Charges 2, 3, 4, 5, 6. 7, 8, 9, 10,... "..:',,,,,~,., :,,~ 11, D E. MOTOR VEHICLE INJURy.."" " ". F. OTHER BENEFITS - Heat Stroke and Heat Exhaustidn will be covered as any other accident. G. FIELD TRIP COVERAGE - all students will be covered for one day field trips, with no o,vernight stay. Basic benefits apply for up to $2,000 per injury. H. ACCIDENTAL DEATH AND DISMEMBERMENT - When injury covered by this policy results in Accidental Death or Dismemberment within 180 days from the date of accident, the following benefits will be payable. Loss of Life $ 2,000 Double Dismemberment $10,000 Loss of an Eye $ 2,000 Single Dismemberment $ 2,000 For specific costs and further details of the coverage, including exclusions, reductions or limitations, and the terms under which the policy may be continued in force, see your agent or write the Company. The amount of benefits provided depends upon the plan selected and the premium will vary with the amount of benefits. 3 S-5725 TX
United I.S.D. Student Extra-Curricular Insurance Sponsor Kit 7-01-10 Sponsor Kit (Student Extra-Curricular Insurance) The following forms make up the sponsor kit for extra-curricular activities. Attached
VICTOR VALLEY UNION HIGH SCHOOL DISTRICT 16350 Mojave Drive Victorville, CA 92395 (760) 955-3201 SUPERVISOR INSTRUCTIONS FOR MANAGING INJURED EMPLOYEES In the event of a life threatening emergency, immediately
Sedgwick Claims Kit Georgia 2014 v2 P.O. Box 14484 Lexington, KY 40512-4484 T: 865-583-8300 F: 865-583-8310 Toll Free: 800-773-4840 Dear Insured: We would like to welcome you as a policyholder of Freestone
RE: Workers Compensation Claims Kit - Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee,
STATE OF NEW YORK WORKERS COMPENSATION BOARD 100 BROADWAY-MENANDS ALBANY, NY 12241 (877) 632-4996 You were injured at work. What now? The New York State Workers Compensation Board has received notice you
SANTA PAULA UNIFIED SCHOOL DISTRICT Risk Management Office 500 E. Santa Barbara Street, Santa Paula, CA 93060 Phone: (805) 933-8800 ex. 9802 Fax: (805) 525-6128 Processing Workers Compensation Forms Attached
Workers Compensation Coverage Claim Kit REPORT A CLAIM: 1-800-824-3313 Client # 007686 SPARTA Insurance Company, (TECIS Program), uses Gallagher Basset to handle all of your claims. To report your workers'
INSURANCE AND LOSS PREVENTION GUIDE This publication has been developed to assist PTA leaders in selecting appropriate fund-raising activities, sponsored programs and events. Using this publication will
Information & Assistance Unit guide 1 How to file a workers compensation claim form Use a claim form to report a work injury or illness to your employer. Attached is the employee claim for workers compensation
Granite School District 2015-2016 Information for Junior & Senior High students (English) * La información se ofrece también en español en este documento * Welcome to the 2015-2016 school year It is important
Employee Claim C-3 State of New York - Workers' Compensation Board Fill out this form to apply for workers' compensation benefits because of a work injury print neatly. This form may also be filled out
TITLE: NUMBER: ISSUER: Child Health and Disability Prevention (CHDP) Program and Blood Lead Testing BUL-2514.1 Michelle King, Senior Deputy Superintendent School Operations, Office of the Superintendent
MENIFEE UNION SCHOOL DISTRICT WHAT TO DO IF YOU ARE INJURED AT WORK 1. Report any injury to your supervisor or his/her designee. If after the hours, contact the Risk Manager the next morning, or the earliest
New Employee s Guide to Workers Compensation Helpful information you should know if you are injured on the job or become ill due to your job. Questions & Answers What is workers compensation? At no cost
new employee s guide to compensation workers Helpful information you should know if you are injured on the job or become ill due to your job. guía para nuevos empleados compensacíon sobre la A LOS TRABAJADORES
New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. PART A: General Information When key parts of the health care law take effect in 2014, there will be a new
LOS ANGELES UNIFIED SCHOOL DISTRICT BULLETIN TITLE: NUMBER: ISSUER: Enrollment/Support of Homeless Children and Youth in Schools Michelle King, Senior Deputy Superintendent, School Operations, Office of
New Employee Paperwork Summary EMPLOYEE NAME WWID The following forms must be signed and collected at New Employee Orientation: Completed by New Hire 1. Appendix A / Employment Agreement 2. Information
Volunteer Handbook 2014-2015 China Spring ISD China Spring Independent School District Mailing: P.O. Box 250, China Spring, TX 76633 Physical: 6301 Sylvia Ave., Waco, TX 76708 254-836-1115; Fax 254-836-0559
Attorneys at Law Información del Cliente Fecha: Fecha del Accidente: Ubicación: Ciudad/Estado/Condado Nombre completo del cliente: Adulto [ ] Menor de Edad [ ] Nombre del Representante Personal: Dirección:
Eligibility Guide for Child Care Centers FY 2015-2016 Child Care Food Program building healthy habits for life Florida Department of Health Bureau of Child Care Food Programs 4052 Bald Cypress Way, Bin