Texas Student Resources

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1 Texas Student Resources Student Athletic/Activities Insurance Mutual of Omaha / United Healthcare HSR Health Special Risk, Inc Toll Free (866) VOLUNTARY STUDENT INSURANCE Fort Worth Christian School Policy Number: T5MP Students may enroll on-line by visiting Enrollment Web Sites. A supply of On-line Enrollment Flyers will be provided to the School District. Schools requiring large numbers of Enrollment Flyers will be shipped boxes divided into quantities of 250. On-line Flyers should be distributed to each campus. On-line enrollment website: Mail-back Enrollment: Complete Enrollment Form and mail to HSR. Mail-back Enrollment Forms can be printed from website Mail-back Enrollment Forms can be printed from PDF.* Portable Document Format (PDF) will be provided to school that includes: *Voluntary Coverage Brochure with mail back option. Voluntary Premier Plan Benefits & Rates. Voluntary Economy Plan Benefits & Rates. Claim Forms: Can be printed from enrollment websites. Links to Enrollment website and HSR can be provided to School District Contact Information Customer Service Health Special Risk Cassandra Talton: Technical Support Health Special Risk Kent Holbert: Supplies / Claims Texas Student Resources

2 Regístrese por Internet Nuestros productos de seguro para estudiantes protegen y ayuda a millares de niños contra los golpes y caídas comunes los niño. ENROLL ONLINE NOW at /12 HSR K-12 STUDENT INSURANCE PLANS Enroll Online The HSR Student Insurance products help protect thousands of kids from the bumps and bruises of growing up. How to Enroll Enrolling online is easy and takes only a few minutes. Please Go to and click the Enroll Now button. Cómo matricularse Matricularse en el internet es fácil y toma unos minutos. Vaya al haga clic en el botón Enroll Now. 1. Enter the name of the school district and state where your child attends school. 2. Enter your student s name and grade level. 3. You will now see the available plans and their costs (rates). Select your coverage and continue to the next step, establishing an account. 4. Please enter information about you, such as your name and address. 5. Next you will enter needed information about your child or children to be covered. 6. Please enter your credit card or echeck payment information. 7. You have successfully enrolled in the HSR K-12 Insurance Program! 8. Finally, print out a copy of the confirmation for your records. 1. Dignos el nombre del distrito escolar y estado en donde su hijo atiende. 2. Necesitamos el nombre de cada estudiante y el grado. 3. Ahora verá los planes disponibles y sus tarifas. Seleccione su cobertura y continúe al próximo paso estableciendo una cuenta. 4. Requerimos información acerca de usted, como su nombre y correo electrónico. 5. Después, usted necesita poner la información de su hijo(s) que estarán cubiertos. 6. Ponga la información de su tarjeta de crédito ó pago por medio de echeck. 7. Exitosamente se ha inscrito en el program de seguro con HSR K Finalmente imprima una copia de la confirmación para que la guarde en su archive. K12 Accident and Health Plans* available through your school include: Injury & Sickness, At-School Accident Only, 24-Hour Accident Only, Extended Dental & Football Seguro Escolar de Accidentes para Estudientes (K-12) y Seguro Medico disponible a través de su escuela: Lesión y enfermedad, Accidentes en la escuela, Accidentes las 24 horas al día, Dental extendido, Fútbol Americano inter escolásticos *Health Plan is only available in Arizona, Colorado, Florida, Georgia, Maryland, North Carolina, Oklahoma, Oregon, Texas and Virginia 2011OLEF If you have questions, please call us at Para preguntas por favor llame al Accident coverage underwritten by Mutual of Omaha Insurance Company, Omaha, Nebraska Health Plan is unwritten by UnitedHealthcare Insurance Company

3 Voluntary Student Accident Insurance TEAS Health Special Risk, Inc. 880 Sibley Memorial Highway Suite 101 Mendota Heights, MN Phone: (Toll-free) (Fax) Fax: HSR is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Mutual of Omaha Insurance Company. Coverage underwritten by: Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE MC34919-T Policy Form T5MP Series 6440S

4 TEAS K-12 Voluntary Student Accident Insurance Coverage ELIGIBILITY: All registered students of a participating school/district in grades PreK-12. COVERAGE OPTIONS AT SCHOOL COVERAGE: Insurance coverage is provided during the hours and days when school is in session, while attending or participating in school sponsored and supervised activities on or off school premises (i.e. day field trips) and while participating in interscholastic athletics (except injuries incurred while participating in High School Football events/activities). Coverage is provided while traveling to, during or after such activities as a member of a group in transportation furnished or arranged by the Policyholder and traveling directly to or from the Insured's home premises and school premises when school is in session. If the Policyholder provides mandatory coverage for students under an At School, Interscholastic Athletic/Activity or Football program, benefits will be payable under those programs before being considered under an At School Voluntary program. 24-HOUR COVERAGE: Provides coverage for injuries incurred 24-Hours a day, 365 days a year, at home, at school and while participating in interscholastic athletics (except injuries incurred while participating in High School Football events/activities). If the Policyholder provides mandatory coverage for students under an Interscholastic Athletic/Activity, Football or At School program, benefits will be payable under those programs before being considered under a 24-Hour Voluntary program. FOOTBALL ONLY: Insurance coverage is provided for High School Football athletes during athletic tryouts, preseason play, practice, state interscholastic governing body approved conditioning, regular and post season play and for travel to, during or after covered athletic activities as a member of a group in transportation furnished and arranged by the school. If the Policyholder provides mandatory coverage for Football athletes under an Interscholastic Athletic/Activity or Football program, benefits will be payable under those programs before being considered under a Voluntary Football Only program. ETENDED DENTAL COVERAGE: This is supplemental coverage for expenses resulting from covered accidental dental injuries. The dental benefits provided are: (a) 100% of U&C Charges for examinations, -Rays, endodontics and oral surgery to a maximum of $10,000; or (b) dental expenses toward the cost of bridges, dentures or replacement of previous dental repairs to a maximum of $250. No coverage is provided for orthodontics (braces) for any reason or damage or loss thereof. Extended Dental Coverage must be purchased in conjunction with a 24-Hour, At School or Football program; it cannot be purchased as stand alone coverage. COVERAGE PERIOD Coverage under the At School, 24-Hour and Football programs begins on the date of premium receipt but not before the start of the school year activities. At School Coverage ends at the close of the regular nine-month school term. 24-Hour Coverage ends when school reopens for the following fall term. Coverage is available under both plans throughout the school year at the premiums quoted (no pro rata premiums available). BENEFITS ACCIDENT MEDICAL EPENSE: When a covered injury to an Insured results in treatment by a physician or surgeon beginning within 60 days of the date of the accident; we will pay benefits as shown in the Schedule of Benefits, in excess of the Medical Deductible, if any. Only eligible medical expenses incurred by the Insured within 52 weeks from the date of the accident are covered. Benefits for any one accident shall not exceed in the aggregate the maximum Medical Benefit of $25,000. Excess Coverage: Benefits are payable for covered expenses that are not recoverable from any other insurance policy, service contract or workers compensation. ACCIDENTAL DEATH AND SPECIFIC LOSS: Benefits are paid for losses incurred within 180 days from the date of Injury. The following benefits (the largest applicable amount) are paid in addition to the medical benefit: Loss of Life... $2, Loss of both hands, both feet, sight in both eyes, speech and hearing... $10, Loss of one hand, one foot, sight in one eye, speech or hearing... $5, Loss of Thumb and Index Finger of the Same Hand... $ "Loss" means, with regard to hands and feet, actual severance above the wrist or ankle joint, with regard to sight, speech or hearing the total and irrevocable loss thereof. Loss means, with regard to thumb and index finger of the same hand, severance of two or more entire phalanges of both the thumb and index finger. DEFINITIONS Injury means accidental bodily Injury: (a) received while insured under this policy; and (b) resulting, independently of sickness and all other causes. Hospital means any of the following places: (a) a place which is licensed or recognized as a general hospital by the proper authority of the state in which it is located; (b) a place operated for the care and treatment of resident inpatients with a registered graduate nurse (RN) always on duty and with a laboratory and -ray facility; (c) a place recognized as a general hospital by the Joint Commission on the Accreditation of Hospitals; or (d) a place certified as a hospital by Medicare. Not included is a hospital or institution or a part of such hospital or institution which is licensed or used principally: (1) for the treatment or care of drug addicts or alcoholics; or (2) as a clinic, continued or extended care facility, skilled nursing facility, convalescent home, rest home, nursing home or home for the aged. Usual and Customary Charges are those comparable charges for similar treatment, services and supplies in the geographic area where treatment is performed. MC34919-T Policy Form T5MP Series 6440S Coverage underwritten by: Mutual of Omaha Insurance Company; Mutual of Omaha Plaza; Omaha, NE 68175

5 ECLUSIONS AND LIMITATIONS This policy does not cover: (1) suicide, attempted suicide or intentionally self-inflicted injury while sane or insane (in Missouri, while sane only); (2) injuries caused by an act of declared or undeclared war; (3) injuries received while in the armed service (upon notice to us of entry into an armed service, the pro rata premium will be refunded); (4) injuries received while acting as a pilot or crew member; (5) injuries resulting from air travel, except while as a passenger for transportation only; (6) injuries resulting from the Insured's engagement in or attempt to commit a felony or being engaged in an illegal occupation; (7) injuries received while under the influence of any controlled substance, unless administered on the advice of a Legally Qualified Physician; (8) injuries received while Intoxicated; (9) injuries sustained while traveling except as described in the covered activities section; (10) the cost of dental treatment, except as specifically provided for Injuries to sound, natural teeth; (11) injuries covered by workers' compensation or employer's liability laws; (12) injury sustained as a result of operating, sitting or riding in or upon, alighting to or from, or working on or around any motorcycle or recreational motor vehicle including but not limited to: two or three wheeled motor vehicle; four wheeled all terrain vehicle (ATV); jet ski; ski cycle; snowmobile or off-road motorized vehicle not requiring licensing as a motor vehicle; (13) injuries sustained while operating a motor vehicle without possessing a current and valid motor vehicle operator s license (except in a Driver s Education Program); (14) injuries sustained while skiing, scuba diving, surfing, roller skating, riding in a rodeo; (15) injuries sustained while skydiving, parachuting, hang; gliding, glider flying, flight in an ultra light aircraft, parasailing, sail planing, bungee jumping, bob-sledding or ballooning; (16) fighting or brawling; except in self-defense; (17) re-injury or complications of a condition for which medical advice or treatment was recommended by a Physician or received from a Physician within a 6 month period preceding the effective date of individual insurance; (18) injuries covered under a mandatory no-fault automobile insurance contract; or (19) expense incurred for treatment of temporomandibular joint dysfunction and associated myofacial pain. STUDENT ACCIDENT INSURANCE SCHEDULE OF BENEFITS INPATIENT: ECONOMY SCHOOL PREMIER OPTION Room & Board/Hospital Miscellaneous Semi-Private Room Rate Semi-Private Room Rate Hospital Miscellaneous Up to $250 first day, to a maximum of $4,000 Up to $250 first day, to a maximum of $5,000 Registered Nurse Up to $400 per injury Up to $400 per injury Physician s Nonsurgical Visits Up to $20 per visit Up to $40 per visit (Benefits are limited to one visit per day and do not apply when related to surgery) OUTPATIENT: Hospital Outpatient Surgery Facility Up to $750 per injury Up to $1,250 per injury Charge Physician s Nonsurgical Visits Up to $20 per visit Up to $40 per visit (Benefits are limited to one visit per day and do not apply when related to surgery or physiotherapy) Physiotherapy Up to $20 per visit, to a $40 maximum (Benefits are limited to one visit per day) Emergency Room Up to $75 per injury Up to $150 per injury (Use of room and supplies; treatment must be rendered within 72 hours from time of injury) -Ray Services (Includes charges for reading) Up to $100 per injury Up to $20 per visit, to a $100 maximum (Benefits are limited to one visit per day) Up to $200 per injury Cat Scan/MRI Up to $250 per injury Up to $500 per injury Laboratory Up to $25 per injury Up to $50 per injury Injections No Benefits No Benefits Prescription Drugs 100% of U&C 100% of U&C Orthopedic Braces and Appliances Up to $300 per injury (When prescribed by a physician for healing) Up to $300 per injury (When prescribed by a physician for healing) Durable Medical Equipment (Post Surgical Only) Up to $150 per injury Up to $150 per injury INPATIENT AND/OR OUTPATIENT: Surgeon s Fees 75% of U&C up to a $3,500 maximum (Limited to the primary procedure per surgery) Anesthetist 25% of surgeon s allowance 25% of surgeon s allowance Ambulance First trip to the hospital, up to a $100 maximum 100% of U&C, first trip to the hospital Consultant No Benefits No Benefits Dental Replacement of Eyeglasses, Contact Lenses & Hearing Aids Up to $150 per tooth (Benefits are paid on sound natural teeth only) 100% of U&C (When broken as a result of a covered injury) 75% of U&C up to a $3,750 maximum (Limited to the primary procedure per surgery) Up to $250 per tooth (Benefits are paid on sound natural teeth only) 100% of U&C (When broken as a result of a covered injury) PLAN & RATE OPTIONS (Make your selection on the enrollment form attached). COVERAGE PLANS ECONOMY OPTION RATES PREMIER OPTION RATES 24-Hour $ $ At School $ $ High School Football $ $ Spring High School Football $ $ Extended Dental $ 8.00 $ 8.00 RETAIN THIS DESCRIPTION FOR YOUR RECORDS. Retain this student accident insurance flyer, and your canceled check, money order receipt or credit card receipt as your record of coverage. This flyer has been designed to illustrate the highlights of this insurance. All student accident insurance information is subject to the provisions of Policy Form T5MP. Exclusions and Limitations will apply. Should there be any discrepancy between the policy and this student accident information, policy provisions will prevail. MC34919-T Policy Form T5MP Series 6440S Coverage underwritten by: Mutual of Omaha Insurance Company; Mutual of Omaha Plaza; Omaha, NE 68175

6 Student s Last Name STUDENT ACCIDENT INSURANCE ENROLLMENT FORM - - Student s Date of Birth Student s First Name MI Telephone Number - - Student s Social Security Number Street # - - Grade Address - City State Zip Code Name of School District (Required to Process) Name of Signature of Parent or Guardian Date Address PLEASE CHECK YOUR SELECTION BELOW: COVERAGE PLANS ECONOMY OPTION PREMIER OPTION 24-Hour $ $ At School $ $ High School Football $ $ Spring High School Football $ $ Extended Dental $ 8.00 $ 8.00 COMPANY USE ONLY: Check # Amount Rec d Enclose check for total payment payable to: Health Special Risk TOTAL All Selections HERE: $ COMPLETE THIS SECTION ONLY IF YOU WISH TO PAY WITH MASTERCARD OR VISA First Name MI Last Name Street # Address - City State Zip Code / Card Number Cardholder Signature A 3% administrative charge will be added for Credit Card Orders Expiration Date (MM/YYYY) Accident Coverage underwritten by: Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE Once completed, mail this form to: Health Special Risk, Inc. P.O. Box Dallas, T For information or to enroll in the Student Health Plan, offered through UnitedHealthcare Insurance Company, please visit us at (Student Health Plans only Available in the following states: Florida, North Carolina, Virginia, Colorado, Arizona, Texas, Georgia, Maryland, and Oregon) MC T Vol Policy Form T5MP Series 6440

7 VOLUNTARIO SEGURO DE ACCIDENTENTE PARA EL ESTUDIANTE TEAS Health Special Risk, Inc. 880 Sibley Memorial Highway Suite 101 Mendota Heights, MN Llamada Gratis: Fax: HSR es una agencia autorizada independiente de seguros y esta autorizada para vender este seguro de accidentes para el estudiante a nombre de Mutual of Omaha Insurance Company. Cobertura Suscrita por: Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE MC34919_SP-T Policy Form T5MP Series 6440S

8 TEAS Cobertura de Seguro de Accidente Voluntario para Estudiantes de K-12 ELEGIBILIDAD: Todos los estudiantes inscritos en una escuela participante / distrito en los grados Pre-K-12. OPCIONES DE COBERTURA COBERTURA ESCOLAR: La cobertura del seguro se proporciona durante las horas y días cuando la escuela está en sesión, mientras se asista a la escuela o se participe en actividades patrocinadas y supervisadas dentro o fuera de las instalaciones de la escuela (es decir, excursiones escolares) y mientras este participando en actividades deportivas ínter escolares (con excepción de las lesiones sufridas durante su participación en eventos/actividades de fútbol americano de la escuela). Se proporciona cobertura mientras este viajando hacia, durante o después de tales actividades como miembro de un grupo en un método de transporte proporcionado o contratado por el Tenedor de la póliza y este viajando directamente desde las instalaciones de la residencia del asegurado a las instalaciones de la escuela cuando la escuela está en sesión. Si el Tenedor de la póliza proporciona cobertura obligatoria para los estudiantes ya sea en el programa de Mientras este en la Escuela, Atletismo/Actividad Ínter escolar o programa de fútbol, se pagarán los beneficios de esos programas antes de ser considerados como un programa Voluntario mientras este en la Escuela. COBERTURA DE 24 HORAS: Provee cobertura por las lesiones sufridas las 24 horas del día, los 365 días del año, en el hogar, la escuela y durante su participación en actividades deportivas ínter escolares (con excepción de las lesiones sufridas durante su participación en eventos o actividades de escuela secundaria de fútbol americano). Si el Tenedor de la póliza proporciona cobertura obligatoria para los estudiantes bajo un programa Atlético/Actividad/ Ínter escolar, fútbol americano o mientras esté en la Escuela, los beneficios de esos programas se pagarán antes de ser considerados bajo un programa Voluntario de 24 Horas. FÚTBOL AMERICANO SOLAMENTE: La cobertura del seguro será proporcionada a los atletas que participan del fútbol americano de escuela secundaria durante las pruebas de aptitud deportiva, el juego de pretemporada, las prácticas, calistenias o acondicionamiento aprobado por el consejo que gobierna las actividades ínter escolares del estado, juegos regulares y postemporada y también para los viajes hacia, durante o después a tales actividades deportivas como miembro de un grupo en un método de transporte proporcionado y organizado por la escuela. Si el Tenedor de la póliza proporciona cobertura obligatoria para los atletas de fútbol americano bajo un programa de Atletismo/Actividad Ínter escolar o de fútbol americano, se pagarán los beneficios de esos programas antes de ser considerados como un programa Voluntario de Football Americano Solamente. COBERTURA DENTAL ETENDIDA: Se trata de una cobertura complementaria para gastos que son el resultado de accidentes dentales bajo cobertura. Los beneficios dentales proporcionados son los siguientes: (a) 100% de las Tarifas U & C para exámenes, radiografías, endodoncia y cirugía oral a un máximo de $10,000, o (b) gastos dentales por el costo de los puentes, las dentaduras postizas o el reemplazo de previas reparaciones dentales hasta un máximo de $250. No se proporciona cobertura para la ortodoncia (frenos) por cualquier razón o por daños o pérdida de la misma. Cobertura Dental extendida debe ser comprado en conjunto con un programa de 24 Horas, mientras este en la Escuela o de Fútbol americano no se puede comprar como una cobertura autónoma. PERIODO DE COBERTURA - Los programas de Cobertura mientras este en la Escuela, el de 24 Horas y el de Football Americano comienzan en la fecha de recibo de primas, pero no antes del inicio de las actividades del año escolar. La cobertura de los programas Mientras este en la Escuela termina al final del termino escolar regular de nueve meses. La cobertura del programa de 24 Horas se termina cuando se vuelve a abrir la escuela para el otoño siguiente. La cobertura está disponible en ambos planes durante el año escolar en las primas cotizadas (sin primas disponibles pro rata). BENEFICIOS GASTOS MÉDICOS POR ACCIDENTE: Cuando una lesión en la cubierta de un Asegurado resulta en el tratamiento de un médico o cirujano dentro de los 60 días siguientes a la fecha del accidente, nosotros pagaremos los beneficios como se muestra en la Tabla de Beneficios, por encima de los Deducibles Médicos, si existiese alguna. Sólo los gastos médicos elegibles incurridos por el Asegurado dentro de las 52 semanas desde la fecha del accidente están cubiertos. Beneficios por cualquier accidente no podrán exceder en conjunto el máximo beneficio médico de $25,000. Exceso de cobertura: Los beneficios se pagan por los gastos cubiertos que no sean recuperados de cualquier otra póliza de seguro, contratos de servicios o de compensación de trabajadores. MUERTE ACCIDENTAL Y PÉRDIDAS ESPECÍFICAS: Los beneficios se pagan por las pérdidas sufridas en los 180 días a partir de la fecha de la lesión. Los siguientes beneficios (el mayor importe aplicable) se pagan además de los beneficios médicos: Pérdida de la Vida... $2, Pérdida de ambas manos, ambos pies, la vista en ambos ojos, el habla y la audición... $10, Pérdida de una mano, un pie, vista en un ojo, del habla o del oído... $5, Pérdida del dedo pulgar y dedo índice de la misma mano... $ "Pérdida" significa, con respecto a las manos y los pies, la ruptura real por encima de la muñeca o del tobillo, en lo que referente a la visión, el oído o del habla es la pérdida total e irrevocable de los mismos. La pérdida significa, en referencia al pulgar y el dedo índice de la misma mano, la amputación de dos o más falanges, tanto el pulgar y el dedo índice. DEFINICIONES "Lesiones" significa lesión corporal accidental: (a) recibido mientras se encontraba asegurado bajo esta póliza, y (b) como resultado, independientemente de una enfermedad y todas las demás causas. "Hospital" significa cualquiera de los siguientes lugares: (a) un lugar que tiene licencia o está reconocido como un hospital general por la autoridad competente del Estado en el que se encuentra, (b) un lugar que opera para el cuidado y tratamiento de los pacientes residentes con una enfermera graduada registrada (RN), siempre en servicio y con un laboratorio e instalaciones de rayos, (c) un lugar reconocido como un hospital general de la Comisión Conjunta de Acreditación de Hospitales, o (d) un lugar certificado como un hospital por Medicare. No se incluye un hospital o una institución o una parte de dicho hospital o institución que tiene licencia o se usa principalmente: (1) para el tratamiento o el cuidado de toxicómanos o alcohólicos, o como (2) como una clínica, centro de atención continuada o extendida, centro de enfermería especializada, centro de convalecencia, casa de reposo, asilo de ancianos u hogar de ancianos. "Las Tarifas Usuales y Normales " son los cargos comparables al tratamiento, servicios y suministros similares en el área geográfica donde el tratamiento se lleva a cabo.

9 ECLUSIONES Y LIMITACIONES Esta póliza no cubre: (1) lesiones de suicidio, intento de suicidio o auto infligidas intencionalmente, mientras este cuerdo o demente (en Missouri, mientras que este solamente en sano juicio), (2) las lesiones causadas por un acto de guerra declarada o no declarada, (3) las lesiones recibido, mientras está en el servicio militar (previa notificación a nosotros de entrada en un servicio de armado, la prima a prorrata será devuelto), (4) las lesiones recibidas al actuar como piloto o miembro de la tripulación (5) lesiones derivadas de los viajes aéreos, excepto cuando un pasajero para el transporte solamente; (6) las lesiones resultantes de la participación del Asegurado en o intento de cometer un delito o que se dedican a una ocupación ilegal; (7) las lesiones sufridas bajo la influencia de cualquier sustancia controlada, a menos que administra el consejo de un Médico Legalmente Calificado; (8) las lesiones recibidas en estado de ebriedad; (9) las lesiones sufridas durante el viaje, excepto como se describe en la sección abarca las actividades; (10) el costo del tratamiento dental, salvo lo dispuesto expresamente por daños causados a sonido, los dientes naturales, (11) lesiones cubiertas por la compensación del trabajador o de las leyes de responsabilidad patronal; (12) los daños sufridos como resultado de la operación, sentarse o andar en o sobre, posándose hacia o desde, o trabajan en o alrededor de cualquier motocicleta o recreativas vehículo, incluyendo pero no limitado a: dos o tres ruedas de vehículos de motor, cuatro ruedas, vehículo todo terreno (ATV), jet esquí, el ciclo de esquí, motos de nieve o fuera de la carretera de vehículos motorizados que no requieren de licencias como un vehículo de motor; (13), mientras que las lesiones sufridas conduciendo un vehículo automotor sin poseer una licencia válida y vigente de operador de vehículos de motor (excepto en el Programa de Educación de conducir), (14) heridas sufridas mientras este esquiando, buceando, surfeando, patinando, montando a caballo en un rodeo; (15) las lesiones sufridas paracaidismo, paracaidismo de caída libre, delta, parapente, vuelo sin motor, vuelo en un avión ultraligero, planeamiento a vela, puenting, trineo o distensión; (16) peleas o enfrentamientos, salvo en defensa propia; (17) Lesionándose nuevamente o complicaciones de una enfermedad para la que se recomienda atención médica o tratamiento de un médico o recibido de un médico dentro de un período de 6 meses anteriores a la fecha de vigencia del seguro individual; (18) heridas cubiertas por un sistema obligatorio de contrato de seguro del automóvil sin omisión; o (19) los gastos incurridos para el tratamiento de la disfunción de la articulación temporomandibular y dolor miofacial asociado. PROGRAMA DE BENEFICIOS DE SEGURO DE ACCIDENTES PARA ESTUDIANTES PACIENTE INTERNO: ECONÓMICA DE ESCUELA OPCIÓN PREMIER Misceláneas por Hospital/Cuarto Tasa de Cuarto Semi-Privado Tasa de Cuarto Semi-Privado &Comida Misceláneos de Hospital Hasta $250 primer día, hasta un máximo of $4,000 Hasta $250 primer día, hasta un máximo of $5,000 Enfermería Certificada Hasta $400 por lesión Hasta $400 por lesión Visitas No Quirúrgicas de Médico Hasta $20 por visita Hasta $40 por visita (Los Beneficios están limitados a una visita por día y no se aplican cuando están relacionados con cirugía) CONSULTA ETERNA: Cargos de Facilidad-Quirúrgica de Hasta $750 por lesión Hasta $1,250 por lesión Consulta Externa de Hospital Visitas No Quirúrgicas de Médico Hasta $20 por visita Hasta $40 por visita (Los Beneficios están limitados a una visita por día y no se aplican cuando están relacionados con cirugía o fisioterapia) Terapia Física Hasta $20 por visita, hasta un máximo de $40 (Los beneficios son limitados a una visita diaria) Hasta $20 por visita, hasta un máximo de $100 (Los beneficios son limitados a una visita diaria) Sala de Emergencia Hasta $75 por lesión Hasta $150 por lesión (Uso de cuarto y suministros; el tratamiento debe ser realizado dentro de 72 horas de la lesión) Servicios de Rayos (Incluye costos por lectura) Hasta $100 por lesión Hasta $200 por lesión Cat Scan/MRI (Imagen de Resonancia Hasta $250 por lesión Hasta $500 por lesión Magnética) Laboratorio Hasta $25 por lesión Hasta $50 por lesión Inyecciones No Hay Beneficios No Hay Beneficios Prescripciones de Medicamentos 100% of U&C 100% of U&C Inmovilizador Ortopédico y Aparatos de Apoyo Hasta $300 por lesión (Cuando sea prescrito por un médico para curación) Hasta $300 por lesión (Cuando sea prescrito por un médico para curación) Equipo Médico Durable (Solamente Hasta $150 por lesión Hasta $150 por lesión Después de la Cirugía) PACIENTE INTERNO Y/O CONSULTA ETERNA: Costos de Cirujano 75% de U&C Hasta un máximo de $3,500 (Limitado al proceso primario por cirugía) 75% de U&C Hasta un máximo de $3,750 (Limitado al proceso primario por cirugía Anestesista 25% de asignación del cirujano 25% de asignación del cirujano Ambulancia Primer viaje al hospital, Hasta un máximo de $ % de U&C, primer viaje al hospital Especialista No Hay Beneficios No Hay Beneficios Dental Hasta $150 por diente (Beneficios son pagados solamente Hasta $250 por diente (Beneficios son pagados solamente con con dientes de color natural) dientes de color natural) Reemplazo de Lentes, Lentes de Contacto & Auxiliares de Auditivos 100% de U&C (Cuando se rompen a causa de una lesión cubierta) 100% of U&C (Cuando se rompen a causa de una lesión cubierta) OPCIONES DE PLAN & TASA (Haga su selección en el formulario de suscripción adjunto). PLANES DE COBERTURA OPCIÓN DE TASA ECONÓMICA OPCIÓN DE TASA PREMIER 24-Horas $ $ En la Escuela $ $ Fútbol Americano de Secundaria $ $ Fútbol Americano de Escuela Secundaria $ $ Dental Extendida $ 8.00 $ 8.00 RETENGA ESTA DESCRIPCIÓN PARA SUS ARCHIVOS. Guarde este folleto de seguro de accidente estudiantil y su cheque cancelado, recibo de orden de dinero o recibo de tarjeta de crédito como su registro de cobertura. Este folleto ha sido diseñado para ilustrar las características de este seguro. Toda información de seguro de accidente estudiantil está sujeta a las disposiciones del formulario de la póliza T5MP. Las exclusiones y limitaciones se aplicarán. En caso de que exista discrepancia entre la póliza y esta información de seguro de accidente estudiantil, las disposiciones de la póliza prevalecerán.

10 FORMULARIO DE INSCRIPCIÓN DE SEGURO DE ACCIDENTES PARA ESTUDIANTES Apellido del Estudiante - - Fecha de Nacimiento del Estudiante Nombre de Estudiante Inicial del Segundo Nombre Número de Teléfono - - Número de Seguro Social Número de Calle - - Grado Dirección - Ciudad Estado Código Postal Nombre del Distrito Escolar (Requerido para el Proceso) Nombre de la Firma de Padre o Guardián Fecha Dirección del Correo Electrónico POR FAVOR SELECCIONE UNA OPCIÓN: PLANES DE COBERTURA OPCIÓN ECONÓMICA OPCIÓN PREMIER 24-Horas $ $ En la Escuela $ $ Football (Fútbol Americano) de Escuela Secundaria $ $ Football (Fútbol Americano) de Escuela Secundaria en la Primavera $ $ Cobertura Dental Extendida $ 8.00 $ 8.00 SOLAMENTE PARA USO DE LA COMPAÑÍA: Cheque # Monto Registrado Adjunte un cheque por pago total pagadero a: Health Special Risk TOTAL de todas las Selecciones AQUÍ: $ COMPLETE ESTA SECCIÓN SOLAMENTE SI USTED DESEA PAGAR CON MASTERCARD O VISA Nombre SN Apellido # de Calle Dirección - Ciudad Estado Código Postal / Número de Tarjeta Firma del Dueño de la Tarjeta Un 3% de cargos administrativos será agregado por Ordenes de Tarjeta de Crédito Fecha de Expiración (MM/AAAA) Cobertura por Accidente suscrito por: Mutual of Omaha Insurance Company, Mutual of Omaha Plaza, Omaha, NE Una vez completado, envíe este formulario a: Health Special Risk, Inc. P.O. Box Dallas, T Por información o para suscribirse en el Plan de Salud de Estudiante, que se ofrecen a través de UnitedHealthcare Insurance Company, por favor visítenos en (Los Planes de Salud de Estudiantes solamente están disponibles en los siguientes estados: Florida, North Carolina, Virginia, Colorado, Arizona, Texas, Georgia, Maryland, y Oregon) Por más información o asistencia referente a Seguro de Estudiantes, comuníquese con el Departamento de Servicio al Cliente al MC _SP T Vol Policy Form T5MP Series 6440S

11 School District: STUDENT CLAIM FORM 1. Please fully complete this form 2. Attach itemized bills 3. Mail to HSR K12claims@hsri.com P.O. Box Carrollton, Texas Phone: (972) Fax: (972) Toll Free (866) * DENOTES REQUIRED INFORMATION PART I POLICYHOLDER S REPORT 4.* Date of Birth * Claimant s Name (injured/ill person) 2.* Social Security Number 3.* Gender M F City and State: School Name: Policy Number: 6.* Address of Injured Person * City * State * Zip 7. Phone Number 8.* (If Minor) Parent s Name & Address * City * State * Zip 9. Parent s Phone Number 10.* Date of Accident/Illness 11. Time of Accident a.m. p.m. 12.* Place where Accident Occurred 13.* Date of First Treatment Dental Claims 14.* Indicate which Teeth were Involved in the Accident 15.* Describe Condition of Injured Teeth Prior to Accident: Whole, Sound, and Natural Filled Capped Artificial 16.* Type of Injury (Indicate Part of Body Injured e.g. broken arm, sprained ankle, etc.) Did Injury Result in Death? Yes No 17.* Describe How Accident Occurred or the Nature of the Illness Give all possible details 18.* Which Best Describes the Activity: Play or practice of interscholastic sports Not school related P.E. class During lunch hour In school bus School sponsored field trip Traveling to/from school Athletic period On school property during school hours School sponsored activity during school hours A spectator 19.* Name of Person Supervising the Activity 20.* If engaged in an Interscholastic Sport at the time of the injury, what was the sport? * Signature of Parent/Legal Guardian: Date: * Signature of School Official: * PART II OTHER INSURANCE STATEMENT Do you/spouse/parent have medical/health care or is the Claimant enrolled as an individual, employee or dependent member of a Health Maintenance Organization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through your employer or other source on you or, if applicable, does your son/daughter have health care coverage as a dependent from your previous marriage as mandated in a divorce decree? Yes No Date: If Yes, name of insurance company Policy # Name of insurance company Policy # If applicable, claimant s primary employer name, address, and phone number If applicable, mother s primary employer name, address, and phone number If applicable, father s primary employer name, address, and phone number IF OTHER INSURANCE OR HEALTH CARE PLANS EIST, PLEASE SUBMIT COPIES of their EPLANATION OF BENEFITS along with your claim. IF NO OTHER INSURANCE or HEALTH PLAN EISTS, PLEASE READ & SIGN BELOW. I agree that should it be determined at a later date there is insurance (or similar), to reimburse HEALTH SPECIAL RISK, INC., or the insurance company to the extent of any amount collectible. Signature of Parent/Legal Guardian: Signature of Witness: Date: Date: * PART III AUTHORIZATION TO PAY BENEFITS TO PROVIDER I hereby authorize medical payments to be made directly to doctor(s), hospital(s), or indicated provider(s) of service(s) in connection with this claim. SIGNATURE I hereby authorize any insurance company, hospital, physician or other person who has attended or examined the claimant to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A photo static copy of this authorization shall be considered as effective and valid as the original. SIGNATURE DATE DATE K12CF

12 FRAUD STATEMENTS General: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Maryland, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony. Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects the person to criminal and civil penalties. Minnesota; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under state or federal law, or both, and may be subject to civil penalties. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in section 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim foe each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. K12CF

13 Listed below are important instructions and comments about filing a claim. YOUR CLAIM FORM 1. This claim form should be fully completed and submitted within 90 days from the date of injury. Be sure to answer and complete the section regarding OTHER INSURANCE STATEMENT, marking either yes or no, and signing the line for authorization, so that HSR and the doctors/hospital may communicate concerning your claim. Incomplete claim forms are one of the most frequent reasons why claim payments are delayed. 2. Only one claim form for each accident needs to be submitted. 3. Once completed, make a photocopy for your records, and mail to the address shown below. 4. DO NOT assume that anyone else will mail this claim form to HSR for you. YOUR BILLS 1. Please advise all doctors/hospitals regarding this coverage so they may forward us their itemized bills. 2. If you have already been to the doctor/hospital and did not know about this coverage, then please send all of the itemized bills to HSR at the address shown below. 3. The bills should include the name of the doctor/hospital, their complete mailing address, telephone number, the date you were seen by the doctor/hospital, what the doctor saw you for (diagnosis) and the specific itemized charges (description of treatment and amount) incurred (including the CPT/procedure code). 4. If this information is not on the bill when you send this in we will have to contact the doctor/hospital which will delay the review of your claim. Balance Due or Balance Forward statements do not contain sufficient information to complete your claim. ECESS INSURANCE (if applicable) 1. This policy may provide coverage on a secondary/excess basis. If you have any primary insurance coverage, you need to send the bills to your primary insurance first. 2. HSR will consider benefits after your other, primary, insurance has processed the claim. 3. We will require a copy of your primary insurance Explanation of Benefits (EOB) which you should receive from your primary insurance letting you know what was paid or denied, and the reason(s) why. 4. HSR will not be able to consider your claim without this information. If you have any questions, please contact Customer Service at (866) They are available from 8:00 a.m. thru 6:00 p.m. central time, Monday Friday. You may also forward any documents by fax to (972) Health Special Risk, Inc. P.O. Box Carrollton, T K12CF