5 8 0 1 E A S T C O N I F E R S T R E E T ◊ O A K P A R K , C A 9 1 3 7 7 ◊ ( 8 1 8 ) 7 3 5 - 3 2 0 0 ◊ ( 8 1 8 ) 8 7 9 - 0 3 7 2 F A X

Re: Student Injuries and Insurance 2015-2016 School Year Dear Parent Legal Guardian: The safety of our students is one of our most important concerns. Even so, accidents do happen and resulting medical treatment (ambulance transport, surgery, hospitalization, etc.) can be very expensive. Please know that the District does not assume responsibility for these costs. However, as a service to you and your child, your school has joined with 1,000’s of others by offering you access to a low cost, voluntary purchase student accident/health insurance program. The program is arranged and administered by Myers-Stevens & Toohey & Co., Inc. a firm that has specialized in such coverage’s for 40 years. Details and an enrollment form are in the accompanying brochure. Please read it carefully. Several plans are offered and rates for the entire school year start at around $24 (Dental Accident Plan). You can limit coverage to school related injuries only (including sports) or opt for 24/7 protection. Also offered is a Student Health Care Plan (recommended if your child has no other health insurance) and a pharmacy discount program for your entire family. Whether your child currently has no other coverage or you want to "fill in the gaps" in other insurance, you will probably find an option to fit your needs. While you can seek care from any doctor or hospital, you'll also have access to an extensive network of medical providers with discounted charges. Seeking care through contracted providers may further reduce your out-of-pocket costs, particularly if your child needs surgery or hospitalization. To enroll, complete the enrollment form in full, select the plan(s) you want for your child, enclose the proper premium using a check, money order or credit card, seal and return as directed on the form. While your child is eligible to enroll at any time, you are encouraged to consider early enrollment to get maximum value from the plan(s) selected. Note - Once processing is completed, an ID card verifying coverage will be mailed home to you. Because many parents have expressed interest in much higher limits of coverage for their children, at that time you'll also be sent information regarding a newly available Supplemental Catastrophic Injury Plan that can cover up to $500,000/injury for up to five years. If you have any questions, please call Myers-Stevens & Toohey at (800) 827-4695. Bilingual representatives are available for parents who need assistance in Spanish. In order to document you having been notified of this matter, please sign and complete the bottom of this form and immediately send it back to the school with your child.

As a parent/guardian of ___________________________________, I understand that the school does not assume responsibility for student injuries but does make voluntary purchase, student accident insurance available. I have received information on this program.

r I will enroll my child in the program r I choose not to enroll my child in the program Signed: _______________________________________ Date: _______________________________________

#26

643

2015-2016

Despitebesteffortstoprotectthem,childrengethurt...sometimesseriously.Obtainingthecaretheyneedcanbeexpensive.

Yourschoolhasarrangedforthesevaluableplanstoassistyouwiththeexpenseofunexpectedemergencies.

Evenifyourchildhasothercoverage,ourplanscanhelpcoverthelargedeductibles,co-paysandotheruncoveredexpensessocommontomanyotherplanstoday.

With Our Plans

• Usethedoctororhospitalyouwant...norestrictions

• EmergencyRoom(room&supplies)andAmbulancecoveredat100%ofUCR*charges!

• Ratesareaffordable

• Enrollmentiseasy-mail,fax,e-mailandonline

Student Accident & Sickness Coverage School Year

PROTECT YOUR CHILD TODAY!*Usual, customary & reasonable

Sponsored by:

Arranged and Administered by:

640

#26

Determine the Plan(s) you want to purchase

You may go to the doctor or hospital of your choice!

Student Accident & Sickness PlanOur Best Coverage!

Students (Grades P-12) may enroll in this plan.CoversInjuriessustainedandSicknesscommencinganywhereintheworld,24hoursaday,whileyourstudentisinsuredunderthisSchoolYear’splan(includinginterscholasticsports,except high school tackle football).RepatriationandMedevacbenefitsareincluded.Thisplandoesnotcoverroutineorpreventativecare.

Benefits are payable according to the “Description of Benefits” up to $50,000 per Covered Sickness and $200,000 per Covered Accident.

Coverage begins at 11:59 p.m. onthedayMyers-Stevens&Toohey&Co.,Inc.(hereincalled“The Company”)receivesthecompletedenrollmentformandpremium.Coverage ends at 11:59 p.m. onthelastdayofthemonthforwhichpaymenthasbeenmade.Coveragemaybecontinuedforupto12calendarmonths,orthroughSept.30,2016,whichevercomesfirst,providedtherequiredpaymentsaremade.Thereisa$50deductiblepercoveredAccidentorcoveredSicknessifenrollingpriortoDecember1,2015.IfenrollingonorafterDecember1,thedeductibleperSicknessisincreasedto$500unlessenrollmentoccurswithin:1)30daysofstudent’stransferintoaparticipatingSchool;or2)30daysoflossofpriorsicknesscoverage;or3)5daysofparticipationinthefirstofficialdayofpracticeforanyinterscholasticsport.Enroll Early!

NOTE–Participationincommercialcampsorclinicsmaybecoveredunderthisplan.

Interscholastic Tackle FootballAccident PlansStudents (grades 9-12) may enroll in these plans.CoversInjuriescausedbycoveredaccidentsoccurring:

•WhilepracticingorplayingininterscholastichighschooltacklefootballactivitieswhichareSchool-sponsoredanddirectlysupervised,includingspringpracticeandsummerconditioning,weighttrainingandpassingleague

•WhiletravelingforfootballinaSchoolVehicleortravelingdirectlyandwithoutinterruptionbetweenSchoolandoff-campussiteforsuchactivitiesprovidedtravelisarrangedbyandisatthedirectionoftheSchool

Coverage begins at 11:59 p.m. onthedaytheCompanyreceivesthecompletedenrollmentformandpremium.Coverage ends at 11:59 p.m. ontheclosingdateofregularclassesforthe2015-2016SchoolYear.

NOTE–Participationincommercialcampsorclinicsisnotcoveredundertheseplans.See“Full=Time24/7”plans.

Benefit Levels: High Mid LowRates per School Year: $339 $295 $235

Full-Time 24/7 Accident PlansStudents (grades P-12 and school employees) may enroll in these plans.CoversInjuriescausedbycoveredAccidentsoccurring24hoursaday,anywhereintheworldandwhileparticipatinginallinterscholasticsports except high school tackle football.

Coverage begins at 11:59 p.m. onthedaytheCompanyreceivesthecompletedenrollmentformandpremium.Coverage ends at 12:01 a.m. onthedateSchoolbeginsregularlyscheduledclassesforthe2016-2017SchoolYear.

NOTE–Participationincommercialcampsorclinicsmaybecoveredunderthisplan.

Benefit Levels: High Mid LowRates per School Year: $328 $276 $225

School-Time Accident PlansStudents (grades P-12) may enroll in these plans.CoversInjuriescausedbycoveredAccidentsoccurring:

•OnSchoolpremisesduringthehoursandondayswhentheSchool’sregularclassesareinsession,includingonehourimmediatelybeforeandonehourimmediatelyafterregularclasses,whilecontinuouslyontheSchoolpremises

•WhileparticipatinginorattendingSchool-sponsoredanddirectlysupervisedSchoolActivitiesincludinginterscholasticathleticactivitiesandnon-contactspringfootball(except interscholastic high school tackle football)

•WhiletravelingdirectlyandwithoutinterruptiontoorfromresidenceandSchoolforregularattendance;orSchoolandoffcampussitetoparticipateinSchool-sponsoredanddirectlysupervisedSchoolActivities,providedtravelisarrangedbyandisatthedirectionoftheSchool;andwhiletravelinginSchoolVehiclesatanytime.

Coverage begins at 11:59 p.m. onthedaytheCompanyreceivesthecompletedenrollmentformandpremium.Coverage ends at 11:59 p.m. ontheclosingdateofregularclassesforthe2015-2016SchoolYear.

NOTE–Participationincommercialcampsorclinicsisnotcoveredundertheseplans.See“Full-Time24/7”plans.

Benefit Levels: High Mid LowRates per School Year: $79 $68 $53

Dental Accident Plan ($75,000 Maximum)Students (grades P-12) may enroll in these plans.CoversInjuriestoteethcausedbycoveredAccidentsoccurring24hoursaday,anywhereintheworld,includingparticipationinallsportsandallformsoftransportation.

Benefits are payable at 100% of the Usual, Customary and Reasonable charges for Treatment of Injured teeth, including repair or replacement of existing caps or crowns.Wedonotpayfordamagetoorlossofdenturesorbridgesordamagetoexistingorthodonticequipment.

Thecoverageprovidesa“BenefitPeriod”ofAccidentdentalbenefitsforuptooneyearfromthedateoffirstTreatment.ThebenefitperiodforanInjurymaybeextendedeachyear,providedthat:coverageisrenewedpriortoOctober1,thestudentremainsenrolledingradesP-12,andwrittennoticeisreceivedbytheCompanyatthetimeofInjurythatfurtherTreatmentwillbedeferredtoalaterdate.

Coverage begins at 11:59 p.m. onthedaytheCompanyreceivesthecompletedenrollmentformandpremium.Coverage ends at 12:01 a.m. onthedateSchoolbeginsregularlyscheduledclassesforthe2016-2017SchoolYear.

$16.00 purchased separately $12.00 when added to any plan(s) purchased

Pharmacy SmartCardAvailabletostudents,theirfamiliesandschoolstaffthroughourpartnershipwithNationalPharmaceuticalServices(NPS),theSmartCardofferssavingsofupto95%ofprescriptiondrugcostsandisacceptedatover63,000pharmaciesnationwide.

Inaddition,theprogramcanprovide“InstantAlerts”topotentialmedicationinteractionstobetterprotectyourfamilyalongwithunique“ProofofSavings”reportsmaileddirectlytoyoueverysixmonths.

Afteryourpaymenthasbeenprocessed,NPSwillsendyouyourIDcard.Presentyourcardeachtimeyouorafamilymemberneedsaprescriptionfilledtoreceiveyoursavings.Formoredetailedinformation,gotowww.pti-nps.comorcall800-546-5677.

TheSmartCardisnotaninsuranceproductandisnotinsuredbyBCSInsuranceCompany.

$36.00 for entire family, for one full year!

1st payment: $208.00(Covers remainder of month in which you enroll and 1 additional month)

Subsequent Payments: $169.00 a month, billed every 2 months

™

#26

Determine the benefit level that best fits your needsWeurgeyoutoconsiderthe Student Accident & Sickness Plan ortheHighOptionplans,especiallyifyourchildhasnootherinsurance.

Callusat800-827-4695forhelp.

Description of Benefits (Applies to all plans except the Dental Accident Plan and Pharmacy SmartCard)WewillpaybenefitsonlyforCoveredInjuriessustainedorCoveredSicknesscommencingwhileinsuredunderthisSchoolYear’splan.BenefitspayablewillbebasedontheUsual,CustomaryandReasonableChargesincurredforcoveredmedicalanddentalservices,asdefinedbythePolicy,subjecttoexclusions,requirementsandlimitations.WedonotpayforaserviceorsupplyunlessitisMedicallyNecessaryandlistedintheDescriptionofBenefitsbelow.Applicablebenefitsmandatedbythestateofresidencewillbeincludedinthecoveredexpenses.Youmaytakeyourchildtoanyprovideryouchoose;however,seekingTreatmentthroughaFirst Health contractedprovidermayreduceyourout-of-pocketcosts.

TofindparticipatingFirst Healthmedicalprovidersnearestyou,call800-226-5116orlogontowww.myfirsthealth.com.

Covered Benefit Levels Low Option Mid Option High Option Student Accident & Sickness Plan

Plan Name MAXIMUMS PER ACCIDENT$50,000 Maximum per Sickness

$200,000 Maximum per Accident

Tackle Football Accident Plan $25,000 $50,000 $75,000

Full-Time 24/7 Accident Plan $50,000 $100,000 $150,000

School-Time Accident Plan $25,000 $50,000 $75,000

Deductible - per condition $250 $100 $50 $50/$500*

Covered Expenses BENEFIT MAXIMUMS BENEFIT MAXIMUMS

Hospital Room & Board-SemiPrivateRoomRate 80% 80% 90% 80%

Inpatient Hospital Miscellaneous Charges 80% to $2,000/Day 80% to $2,500/Day 90% to $3,000/Day 80% to $4,000/Day

Intensive Care Unit 80% to $2,000/Day 80% to $2,500/Day 90% to $3,000/Day 80%

Hospital Emergency Room(room&supplies)incurredwithin72hoursofanInjury 100% 100% 100% 100%

Outpatient Surgical(room&supplies) 80% to $2,000 80% to $2,500 90% to $5,000 80% to $4,000

Physician Non-Surgical Treatment & Exam (excludingPhysicalTherapy)Includingconsultation(whenreferredbyattendingPhysician)

80% 80% 90% 80%

Surgeon Services 80% 80% 90% 80%

Assistant Surgeon Services 80% 80% 90% 80%

Anesthesiologist Services 80% 80% 90% 80%

Physiotherapy(includesrelatedofficevisits)whenprescribedbyaPhysician 80% to $400 80% to $750 90% to $1,000 80% to $2,000

X-Ray Examinations(includingreading) 80% to $400 80% to $750 90% to $1,000 80%

Diagnostic ImagingMRI,CatScan 80% 80% 90% 80%

Ambulance(fromsiteofanemergencydirectlytohospital) 100% 100% 100% 100%

Laboratory Procedures, Registered Nurse Services, and Rehabilitative Braces 80% 80% 90% 80%

Durable Medical Equipment 80% to $400 80% to $750 90% to $1,000 80%

Out-Patient Prescription Drugs(forInjuriesonly) 80% 80% 90% 80%

Dental Services(includingdentalx-rays)forTreatmentduetoacoveredAccident 80% 80% 90% 80%

Eyeglass Replacement(forreplacementofbrokeneyeglassframesorlensesresultingfromacoveredAccidentrequiringmedicalTreatment)

$300 $300 $300 80%

Medical Evacuation & Repatriation $0 $0 $0 100% to $10,000

*If enrolling on or after Dec. 1, deductible per Sickness is increased to $500. See Student Accident & Sickness description at left for exceptions.

Benefits for Accidental Death, Dismemberment, Loss of Sight, Paralysis and Psychiatric/Psychological Counseling

Premiums Cannot Be Refunded Or Converted

(Applies to all plans except the Dental Accident Plan and Pharmacy SmartCard)

Inadditiontomedicalbenefits,if,within365daysfromthedateofAccidentcoveredbythepolicy,bodilyInjuriesresultinanyofthefollowinglosses,wewillpaythebenefitsetoppositesuchloss.Onlyonesuchbenefit(thelargest)willbepaidforallsuchlossesduetoanyoneAccident.

•AccidentalDeath $10,000•Singledismembermentorentirelossofsightinoneeye $20,000•Doubledismembermentorentirelossofsightinbotheyes,orparaplegiaorhemiplegiaorquadriplegia $30,000Counseling-InadditiontotheAD&Dbenefits,wewillpay100%oftheUsual,CustomaryandReasonablecostsofpsychiatric/psychologicalcounselingneededaftercovereddismemberment,lossofsightorparalysisupto $ 5,000

#26

X

2015-2016 Enrollment Form

Complete all information (please print) and return to Myers-Stevens & Toohey & Co., Inc.

Student Name First Middle Last

- -Student Birthdate

Mailing Address Apt.#

City State Zip Code

- -

Parent Daytime Phone Number

Parent E-mail Address

District Name

School Name Grade

Availableforyourconvenienceistheoptiontohaveyourbi-monthlypaymentsautomaticallychargedtoyourcreditcard.

Byinitialinghere______________,IherebyauthorizeMyers-Stevens&Tooheytochargetheabovecreditcard$338,plusa3%processingfee,onthe5thofthemonththatmypaymentisdue.Thisauthorizationwillremainineffectforthe2015/2016schoolyearuntilInotifyMyers-Stevens&Tooheyinwritingpriortothenextpaymentdate.

Auto-Charge Option

Method of PaymentNote: $25.00 service charge for Returned Checks and declined Credit Cards

Check/Money Order(Makepayableto:Myers-Stevens&Toohey&Co.,Inc.)or Mastercard® or Visa®

Important: If paying by credit card, complete this form. Your amount of charge will appear as “M-S Student Insurance” on your statement.

- - -

Card Number 3 digitcontrol #

EXP. DATE MO. YR.

Signature of Cardholder

Amount

$

I authorize Myers-Stevens & Toohey & Co. Inc. to deduct the premium payment, plus a 3% processing fee, from my credit card. If enrolling in the Student Accident & Sickness Plan, I am authorizing the initial premium payment and understand that I will be invoiced every 2 months for the subsequent payments.

Print Name of Cardholder Zip Code

1

2

3

2

1

Student Accident & Sickness 1st Payment $208.00

Youwillbebilled$338.00every2monthsthereafter.Coveragecannotexceed12calendarmonthsorrunpastSept.30,2016.

(One-Time Payment For Entire School Year)

PLANS: High Option Mid Option Low OptionTackle Football Only $339.00 $295.00 $235.00

Full-Time (24/7) $328.00 $276.00 $225.00

School-Time $79.00 $68.00 $53.00

Dental Accident $16.00 Purchased Separately

$12.00 When added to any plan(s) purchased

Pharmacy Smart-Card

$36.00

Total Amount Due $

Print Parent or Guardian NameIhaveenrolledforthecoveragecheckedaboveasprovidedbytheFamilyInsuranceTrustwhereapplicable.Iunderstandpremiumscannotberefundedorconverted.

X__________________________________________________Parent or Guardian Signature Date

Our BEST Plan

Our Accident Plans

PREMIUMS CANNOT BE REFUNDED OR CONVERTED

InstructionsThank you for enrolling your child!

To avoid any delay in coverage, please follow these 3 easy steps below: Selecttheplan(s)youwishtopurchasebelow:

• TheStudentAccident&SicknessPlanwillprovideourhighestlevelofcoverage.

• OurAccidentPlansmaybepurchasedonanindividualbasisorcombinedwithadditionalcoverage(forexample,Full-TimeAccident+Dental).

Completeanddetachtheenrollmentformonthereversesideoryoumayenrollonline(seebelow).Pleasenote,weareunabletoacceptenrollmentsoverthephone.

Purchase and ReturnApply online at www.myers-stevens.com for IMMEDIATE processing!

We accept VISA, MasterCard and personal checks online.

Ifonlineenrollmentisnotavailable,youmayeither:• FaxbothsidesofthecompletedEnrollmentFormto (949)348-2630.You

maypaybycreditcardbycompletingthepaymentareaonreverseorfaxapersonalcheckmadepayabletoMyers-Stevens&Toohey&Co.,Inc.Please do not mail original checks if faxing. WecannotacceptMoneyOrdersbyfax.

• EmailascannedimageofthecompletedEnrollmentFormtoapply@myers-stevens.com.YoumaypaybycreditcardbycompletingthepaymentareaonreverseorscanapersonalcheckmadepayabletoMyers-Stevens&Toohey&Co.,Inc.Please do not mail original checks if emailing. WecannotacceptMoneyOrdersbyemail.

• MailbothsidesofthecompletedEnrollmentFormintheenclosedenvelope.YoumaypaybycreditcardbycompletingthepaymentareaonreverseorencloseacheckorMoneyOrdermadepayabletoMyers-Stevens&Toohey&Co.,Inc.

PLEASE DO NOT SEND CASH

#26

Frequently Asked Questions...

I’m in a hurry! What is the quickest way to enroll?Weofferonlineenrollmentat

www.myers-stevens.com.Simplyclicktheorange“EnrollNow”buttononthehomepage,complete the enrollment process and your ID card will beemailedtoyouimmediately!

If my child has no other insurance, what’s my best buy?Unless youneedcoverage for high school tackle football, theStudent Accident & Sickness Plan isourbroadest,bestoption.NextbestistheFull Time 24/7 Accident Planwith“HighOption”benefits.

If I have other insurance, why do I need thiscoverage?

Ourplanscanexpandyourchoiceofprovidersforyourchildandcanhelpcoverdeductibles,co-paysandotherout-of-pocketexpenses.

Can I take my child to any doctor or hospital?YES!However,yourout-of-pocketcostscouldbelessbyusingaFirst Health contractedprovider.Tofindparticipatingdoctors/hospitalsnearestyou,call800-226-5116orlogontowww.myfirsthealth.com

Are accident-only rates paid every month?NO!Accident-onlyratesareone-timechargesfortheentireSchoolYear.

Can interscholastic high school tackle football be covered?

YES!ButonlyundertheInterscholastic Tackle Football Plan.“HighOption”benefitsarerecommended.

Do the Interscholastic Tackle Football or School-Time plans cover camps and clinics sponsored and organized by groups other than my child’s school?

NO!However,suchcampsandclinicsmaybecoveredunderourFull-Time 24/7orStudent Accident & Sickness plans.Callusforguidance!

Still need help or have questions?Gotowww.myers-stevens.comorcallusforprompt,personalizedassistanceat(800)827-4695.

How To File A Claim

1.ReportSchool-relatedInjurieswithin60daystotheSchooloffice.TofindaFirst Healthprovidernearestyou,call800-226-5116orlogontowww.myfirsthealth.com.

2.ObtainaclaimformfromtheSchoolortheCompany.ClaimformsmustbefiledwiththeCompanywithin90daysafterthedateoffirstTreatment.

3.Atthesametime,pleasefileaclaimwithyourotherfamilysicknessand/orAccidentcarrier.

4.FollowALLclaimforminstructions,attachallitemizedbillsandsendto:

Myers-Stevens & Toohey & Co., Inc.26101 Marguerite Parkway

Mission Viejo, CA 92692-3203949-348-0656 or 800-827-4695

Fax 949-348-2630CA License #0425842

The Insurance Company

(Does not apply to the SmartCard)

Thisbrochurecontainsabriefdescriptionofthe benefits available.Complete detailsmaybefoundinthePoliciesonfileatyourSchoolor district office. Certain provisions may bedifferentifrequiredbystatelaw.Pleasekeepthisinformationasareference.

Policyholder:FamilyInsuranceTrust,SitusedinDistrictofColumbia

BCS Insurance Company Oakbrook Terrace, Illinois

RatedA-(Excellent)byA.M.Best,anindependentinsurancecompanyratingagency

MasterPolicyform#28.203

#26

CA PND 640 04/15

Exclusions

Benefits are not payable for any of the following or loss that results from them: 1. Damagetoorlossofdenturesorbridgesordamagetoexistingorthodonticequipment.

2. Waroranyactofwar,declaredorundeclared.

3. Participationinariotorcivildisorder;fightingorbrawling,exceptinself-defense;commissionoforattempttocommitafelonyorviolatingorattemptingtoviolateanydulyenactedlaw.

4. Suicide,attemptedsuicideorintentionallyself-inflictedInjurywhilesaneorinsane.

5. InjuryorSicknesscontributedtobytheuseofalcoholordrugsunlesstakeninthedosageandforthepurposeprescribedbytheCoveredPerson’sPhysician.

6. Practice or play in interscholastic high school tackle football (unless separate football coverage is purchased), intercollegiate sports, semi-professionalsports,orprofessionalsports.(DoesnotapplytotheDental Accident Plan.)

7. InjuryorSicknesscoveredbyWorker’sCompensationorEmployer’sLiabilityLaws,orbyanycoverageprovidedorrequiredbylawincluding,butnotlimitedtogroup,grouptype,andindividualautomobile“NoFault”coverage(excludingSchoolVehiclecoverage).

8. Treatment,servicesorsuppliesprovidedbytheSchool’sinfirmaryoritsemployees,orPhysicianswhoworkfortheSchool,orbyanymemberoftheCoveredPerson’simmediatefamily;orforwhichnochargeisnormallymade.

9. Mentalornervousdisorders(exceptasspecificallyprovidedbythePolicy).

10. TreatmentofSickness,ailment,orinfections(exceptpyogenicinfectionsorbacterialinfectionswhichresultfromtheaccidentalingestionofcontaminatedsubstances).(DoesnotapplytotheSickness-OnlyCoverageundertheStudent Accident & Sickness Plan.)

11. ThediagnosisandTreatmentofnon-malignantwarts,molesandlesions,acneorallergies,includingallergytesting.

12. Injurysustainedasaresultofridinginoron,enteringoralightingfrom,atwoorthree-wheeledmotorvehicle.(Doesnotapplytothe Dental Accident Plan.)

13. Treatmentofosteomyelitis,pathologicalfracturesandhernia.(DoesnotapplytotheSickness-OnlyCoverageundertheStudent Accident & Sickness Plan.)

14. Detachedretina(unlessdirectlycausedbyanInjury).(DoesnotapplytotheSickness-OnlyCoverageundertheStudent Accident & Sickness Plan.)

15. Any expenses related to the Treatment of tonsils, adenoids, epilepsy, seizure disorder or congenitalweakness; or expenses for Treatment of congenitalanomaliesandconditionsarisingorresultingdirectlytherefrom.

16. Supplies,exceptasotherwiseprovidedinthePolicy.

Requirements and LimitationsAggravationsofinjurieswhichdidnotoccurwhileinsuredunderthisplanarepaidupto$500maximumbenefitperpolicyterm.Injuriessustainedasaresultofridinginoron,enteringoralightingfromorbeingstruckbyaMotorVehiclearelimitedtoa$5,000maximumbenefit(upto$10,000ifvehicleisaSchoolVehicle).SomeMotorVehicleinjuriesarenotcovered-seeexclusionsabovefordetails.School-timeandhighschooltacklefootballinjuriesmustbereportedtotheSchoolwithin60daysofthedateofInjury.ThefirstPhysician’svisitmustbewithin120daysaftertheAccidentoccurs.Thisinsurancedoesnotapplytotheextentthattradeoreconomicsanctionsorregulationsprohibitusfromprovidinginsurance,includingbutnotlimitedto,thepaymentofclaims.AclaimformmustbefiledwithMyers-Stevens&Toohey&Co.,Inc.within90daysafterthedateofloss.TheplanpaysforcoveredexpensesincurredwithinuptoayearfromthedateofthefirstPhysician’svisit.However,shouldtheInjurysustainedrequiretheremovalofsurgicalpins,continuedTreatmentforseriousburns,orTreatmentofanon-unionormal-unionfracture,thebenefitperiodwillbeextendedto104weeks.Eachcoveredconditionmaybesubjecttoadeductible-seeplandetails.

DefinitionsAnAccidentisdefinedasasudden,unexpectedandunintendedincident.Covered AccidentmeansanAccidentthatresultsinInjuryorlosscoveredbythisPolicy.AnInjuryisdefinedasAccidentalbodilyharmsustainedbytheCoveredPersonthatresultsdirectlyfromanAccident(independentlyofallothercauses)andoccurswhilecoverageunderthePolicyisinforce.Medically NecessaryisdefinedastheservicesorsuppliesprovidedbyaHospital,Physician,orotherproviderthatarerequiredtoidentifyortreatanInjuryorSicknessandwhich,asdeterminedbytheCompany,are:(1)consistentwiththesymptomsordiagnosisandTreatmentoftheInjuryorSickness;(2)appropriatewithregardtostandardsofgoodmedicalpractice;(3)notsolelyfortheconvenienceoftheInsuredPerson;(4)themostappropriatesupplyor levelofservicewhichcanbesafelyprovided.Whenappliedtothecareofan Inpatient, it furthermeansthat the InsuredPerson’smedicalsymptomsorconditionrequiresthattheservicescannotbesafelyprovidedasanOutpatient.SicknessisdefinedasillnessordiseasecontractedbyandcausinglosstotheInsuredPersonwhoseSicknessisthebasisofclaim.AnycomplicationsoranyconditionarisingoutofaSicknessforwhichtheInsuredPersonisbeingtreatedorhasreceivedTreatmentwillbeconsideredaspartoftheoriginalSickness.School Activities meansanyactivitythatissponsoredandunderthedirect,immediatesupervisionoftheSchoolthat:(a)theSchoolrequirestheInsuredPersontoattend;or(b)isunderthesolecontrolandsupervisionofSchoolauthorities.Itdoesnotincludeanactivityrelatedtoathleticsorcheerleadingthatisunderjointsponsorshiporsupervisionarrangementwithanynon-Schoolgroup.

Non-Duplication of Benefits (Excess Provision):Inordertokeeppremiumsasaffordableaspossible,theseplanspaybenefitsonanon-duplicatingbasis.Thismeans,ifapersoniscoveredbyoneormoreoftheseplansandbyanyothervalid insuranceorhealthagreement,anyamountpayableorprovidedbytheothercoverageswillbesubtractedfromthecoveredexpensesandwewillpaybenefitsbasedontheremainingamount.

IMPORTANT NOTICE: This Plan provides short-term limited duration sickness benefits. It does not constitute comprehensive health insurance coverage (often referred to as “major medical coverage”) and does not satisfy a person’s individual obligation to secure the requirement of minimum essential coverage under the Affordable Care Act (ACA). For more information about the ACA, please refer to www.HealthCare.gov.

Premiums Cannot be Refunded or ConvertedFor a brochure in Spanish, or for assistance in Spanish, please call 800-827-4695

Para un folleto en Español, o para asistencia en Español, por favor llame a 800-827-4695

#26