July 1, 2016

To Whom It May Concern:

We are sorry that your child was recently injured during a school activity. The purpose of this packet is to educate you about the Student Accident Insurance coverage that Campbell County Schools maintains on all of their students during the school year. It is our intent to make sure you have as much information regarding this insurance as possible and insure that you have all the necessary forms required to initiate a claim and submit the items for payment. The Student Accident Insurance maintained by Campbell County Schools is supplemental insurance. This insurance can be primary insurance if the student is not covered by any other insurance policy. Please read the attached information carefully.

Included in this packet is the following information: 1) Instructions for filing a claim

2) Claim Form

3) Policy benefit information & limitations

Our local representative for this policy is Crawford Insurance. If at any point in this process you have questions regarding your claim or the process please contact Monette Pillow at Crawford Insurance for assistance. Monette can be reached at 859-581-2088 or via email at monette@crawfordins.com.

Sincerely,

Joe BuerkleyAssistant Superintendent of Operations

CAMPBE,LL COI]NTY SCHOOLSIMPORTANT DOCUMENT STUDENT/ACCIDENT INSURANCE - . - 2016.17

Dear Parelrt/Guardian:

The Campbell County Scltools has purchased accident insurance for all students. The insurance plan provides benefits for accidentalinjury while attending assigned classes or during school sponsored and supervised activities.

The insrrrance plan provided bythe Carnpbell County Sclrools does not pay l}}o/rof all medical and dental expenses (SeeLimitations). Please note that the insurance provided by the Caurpbell County Schools is "secondary,'to any other farnily insuranceplans and will pay only the eiigible tredical expenses not payable by other insurance sources. Folloy,ing is infornration outlining thebn,rnftt ,,.,d li,rritotio,rt qttlr" trhool pru"rlrorod i,rrr,ror.n plo,r.

BENEFITSIf accidental bodily iniury occurs r'r'hile participating in a school sponsored and supervised activity and requires treatment within 30days from the original date of injury by a Iicensed Physician, or trlatment in a legally constituted hospital, the insurance company willpay the reasonable and customarv expenses for necessary nredical" dental or trosp'itai care provided witSin one year from the date of theinjury up to the policy tttaxin ut.t] anlount for any one injury. which are not paid by other collectible insurance plans. The insuredshall have free choice of a physician or lrospital for treainrent" If. however, an insr.rred has other valid coverage through anotherinsurance plan(s) and does not choosr: a physician or hospital tlrrough the other plan, we will pay benefits as if the other plan,sguidelines had been fottowed. (SEE LIMITATIONS enf_OW).

-

LIMITATIONS' Maximum Medical Bene.fit ($25,000 per injury) ' Diagnostic x-rays, MRt's, cA r scans ($400 per injury)' Hospital lnpatient (semi-private room) tnpitient miscellaneous charges($3,000 maximum)' outpatient hospitat charges - Non-surgical ($500 maximum) . oi,tpi1,19n1 Hospitat surgical ($2,000 maximum).' Physician's surgery/fracture care fees (-R & c $3,0oo maximum). iif"iiiur't non-surgicitro,ls oi

"ors, ltations($35 per visit)' Physical rherapv ($35/visit - $280 maximum) , ofthopedic Appliance($3Oo maximum). Dental ($200 per tooth) . Motor Vehicte ($500 per injury).' Ground Ambulance ($10-0 per injury) . Eyeglasses ($100 per injury). Outpatient Prescription Drugs (g10b per injury)

. R & C means Reasonable and Customary

EXCLUSIONS...THE FOLICY DOES NOT COVIR1' contact lenses or hearing aids; damage to other than whole, sound, natural leeth or to existing dental bridge, crowns, restorations, or bracesi orthodonticprocedures and services; drugs, injectioni, rniscellaneous supplies and medications except while hospital confined.2 Boils' athlete's foot impetigo orsimilarskin infections, rashes, porsonorc u"g"t"tion reactions, *jrt", uri.i"r", calluses, cramps, muscle spasms, allergiesor allergic reactions' ingrown nails, appendicil.is hernia of any kino, noweverirriuo;'inr".rion, o..rrring'oin;r-inrn ,. a resurt of such injury; detached relina;or psychiatric care.3 Any form of illness' sickness or disease including but not limited to the following: perthes Disease, osgood-schlatter,s Disease, osteomyelitis,oseteochondritis, osteogenesis.lmperfecta, lilippedcapital Femoral rplpnvrir, in"'"mbophlebitis, Hysterical Reaclions, or simitar condilions.4 Anyformofcriminal orfeloniousassaultoriheinsured'sueingengigejinrriii"g.r

occupalion.

,3r3ffi"[j'r""1$"J*Tii'r'l,iir"J,'##,["":"n""' servicJ bv i tiospitaf pnv-r'i",rn, or person emproyed or rerained by rhe sponsor, or by a person6' Ridinginoron'beingstruckby'oeingtowedSy,boardingoralightingfrom.oroper*i1s^lly.motorizedorenginedrivenvehicre;

provided, however,thateligible medical expenses not collected from otner vatiJ.ororg" wr-lt bJpayabie ,p to ssoo oo in the aggregate.7. lntentionally self-inflicted injury. War or act of war

.ir!ffi?:Hf,i?',:l#f.ofi::,:?ffi*;[::tfi:'J,[:l"lL:?Tjs,are pavabre under anv Workmen's compensarion or Emproyer Liabirity Laws, orwhire

,.3r,i-';il''3Jr'J.iHJ!I.Hr"iJ,|,'iXijl: :"""[*J peison is ridins as ,lrrr.ng". in a ricensed airprane provided by an incorporated passenser carrier on al0 Ridingrnoron'beingstruckny'-terngtow-'dby,o"r11l1n-?lalightingfrom..oroperalinganysnowmobileortwoorthreewheeredmotorvehacre.

l1 The use of orwhile under.lhe inJluende otorugi oiinroxicants unlesJadministered as prescribed bya physician.12'Theexistenceoragsravationofphysical orr""ntrr iniirmity,condiiio;;;;;;"riulirnutn"rinr""riorl,.[n6.-iif,r,ru"ono"ryoracquiredinorigin. conditionsorthe aggravation of conditionslhat originatecr priorio in" rrri"o p-ersors

";;""r; unoerthe poricy.

l:,,5ffiff:;n'J'#",::lli:f:",,r:H[*ru1***l1,;;;;,fi-ili; o"=r'Jr",1,", in rhe absence or rhis insurance, under any hish schoor or associarion

Ifyou have any questions about the l.

, SCHOi-ASTIC INSTJRORS.INC"P O BOX 3194

.IOHNSON CITY TN 37602r -800-872- 1 953

RETATN rHrs DEScRiFToN oFEGffi This is a brief description of thElii?6ffiiiE

AS.OO

GROUP ALL SCHOOL INSURANCE CLAIMPLEASE READ CAREFULLY

CLAIM PROCESSING* * See Reverse side * *

SCHOLASTIC INSURORS, INC,P. O. Box 3194, Johnson City, TN 37602-3194

FORM

PART ASCHOOL OFFTCIAL TO COMPLETE

1) Name of SchoolSchool Address

Name of School System

(City) (State) (zip)2. Name of Injured Student (Print) Grade Age

lFirst) (Middle) (Last)

3. Date of lnjury Time of Injury4. Under whose supervision? Title5. The accident was incurred while the student was parlicipating in:

(check one) _ Game Practice _ P.E. _Travel _ Other6. At the time of the injury, was the student involved in a school sponsored and supervised activity? yes _ no7. Describe the accident fully. How did the accident happen?

Repofted by:ure of School Otllcial) (Tirle) (Date)

PART B: PARENT/GUARDIAN STATEMENT

FATHER oT GUARDIAN

(ciry) (state) (zip)

Phone Ernail

Employer Name and Address

(city) (state) (zip)

Name & Address of'Other Insurance Company

r Group [] Individuiil t IIMO/PPO

MOTHER oT GUARDIAN

(crty) (state) (zip)

Phone Email

Employer Name and Address

(city)

Name & Address of Other Insurance Company

Policy/Group No.Grouo Individual HMO/PPO

crime.l. Iunderstandthat Irnustfurnish,withthisclaim,astatementfrom mypersonal insurancecompanyindicatingtheir

allowable benefits or their reason for refusal to pay" I further understand this claim rvill remain pending until this information is provided.

hospital renderirtg service unless I have checked belou,. _ I do not authorize an assignment and request that benefits be paid directly to me.3. Iherebyauthorizeanyinsurancecompany.hospital.physician,orotherpersonwhohasattendedorexaminedtheclaimanttodisclosewhenrequestedtodosoby

Reliance Standard Life insurance Company, or its representativc. any and all information with respect to any injury. policy coverage. medical history. consultation,

choose a physician or hospital through tlre other plan, Reliance Standard Life will pay benefits as ifthe other plan's guidelines had been fbllor.ved.5. I certily that I have read and understand itenrs l- 4 (above) and I have read and understand the infomration on the reverse side ofthis form.

(Signature ofParent or Guardian)

PART C: F.OR DENTAL INJURYTo be completed by dentist in the event ol injur)' involving treatment to one or nlore teeth. Not to be used as a fbr a copy olthe actual itemized charges.

l. Identily injured teeth by tooth No.2. Previousconditionofiniuredteeth: t-lWhole"sound.rlatural; ! Filled; ! Decayed; n Rootcanal treated; !Other(describe)(Date) Dentist's Nanre 1 Print.l Dentist's S

F.4.&AS-B

NOTE: PLEASE READ THIS BEFORE SUBMITTING A CI}IIM

INSTRUCTIONS FOR FILLING OUT THIS CLAIM FORM

IMPORTANT!!Ir Treatment Must Begin Within 30 Days From Date Of Accident

. Completed Claim Form Must Be Submitted Within One (l) Year From Date Of Accident. All Treatinent Must Be Received Within One (1) Year Of Accident

NOTE: TO SCHOOL PERSONNEL AND PARENTSOur objective at Scholastic Insurors is to provide fast and accurate claims service. Listed below areinstructions that, when followed, will assist us in providing this service.

WHEN To FILE A CLAIM1. Since the policy contains an EXCESS MEDICAL EXPENSE BENEFIT, YOU MUST FIRST FILE

TIIE CLAIM WITH ANY OTIIER INSURANCE (including mqior medical, HMO, PPO,Champus, etc.) so we may determine what payments, if any, we owe. *

2. The completed claim form and supporting documents must be received by Scholastic Insurorswithin one (1) year after the date of accident.

HOW TO FILE A CLAIM1. Part A and Part B must be completed in full

2. lnthe event the claimant sustained a dental iqiury, Part C must be comoleted in full by the dentistproviding treatment

3. Attach itemized bills showing the: (a) name of patient, (b) diagnosed condition, (c) date(s) oftreatment, (d) nature of treatment, and (e) charge per treatment.

4. SINCE THE PoLICY CONTAINS AN EXCESS MEDICAL EXPENSE BENEFIT, we also need:

A. Statement(s) from the other insurance company(ies) or plan(s) showing the payment(s) orrejection of the claim; or

B. If the insured has no coverage, a written statement from the insured's parent's employer(s)

verifying there is no coverage for the insured.

WIIERE TO FILE A CIA,IMSend all completed forms, itemized medical bills, etc., to:

SCHOLASTIC INSI.JRORS, INC.P.O. BOX 3194JOHNSON CITY, TN 37602-3194Telephone: 423-928-73E1 Fax: 423-928-2761

* The insured shall have free choice of a physician or hospital fot trcolmenl, Itl, however, an insured has other

valid coverage through another insurance plan(s) and does not choose a physician or hospital through the otherplan, w,e will pay benefits as if the other plan's guidelines had beenfollowed