TAYLOR COUNTY VOLUNTARY STUDENT ACCIDENT RENEWAL
Posted On:
Tuesday, May 13, 2014
Attention Parents: Accident Insurance Available for Purchase

Below please find the information and application for accident insurance available for parents to purchase for their student.

 

 

Voluntary

 

Student Accident

 

Medical Insurance Program

 

Administered By:

 

Fowinkle School Insurance Agency

 

120-53

 

 

 

rd AvenueWest

 

Bradenton, FL 34207

 

1-800-541-5256

 

Underwritten by

 

Gerber Life Insurance Company

 

Coverage available in Florida only. Please contact National Representative.

 

GER_0414-SA-V-0152

 

STUDENT ACCIDENT MEDICAL INSURANCE

 

Educators and administrators are looking for an accident medical insurance program their school(s) need and students deserve. The

 

Student Accident insurance program underwritten by Gerber Life Insurance Company (the Company) is such a plan. A.M. Best rates

 

Gerber Life "A" (Excellent) for financial condition. For the latest information on ratings, please visit www.ambest.com.

 

OPTIONAL COVERAGE**

 

WHO IS COVERED AND WHEN

 

Eligibility:

 

 

 

 

 

All enrolled students of the school, Pre-K through 12th grade, if premium is paid for.

 

**Under “Optional Coverage” all students must be given the opportunity to enroll. Premiums are the

 

responsibility of the individual student and/or their parent/legal guardian.

 

OPTIONAL SCHOOL-TIME ACCIDENT COVERAGE

 

Coverage and Limitations stated for Medical Expense Benefits selected by the Insured apply. The School-Time Accident

 

Coverage excludes students participating in high school interscholastic tackle football or as stated for in the Application. Each

 

Insured who pays the additional premium required for this benefit is insured under this provision. Coverage starts on the date of

 

premium receipt by the Plan Administrator, but not before the start of the school year. The Insured’s coverage will end at the

 

close of the regular nine-month school term, except while the Insured is attending academic classroom sessions exclusively

 

sponsored and solely supervised by the school during the summer. All provisions of the Policy, including all Coverage and

 

Limitations, Maximums and Exclusions, apply to Insureds covered under this provision.

 

OPTIONAL 24-HOUR ACCIDENT COVERAGE

 

Coverage and Limitations stated for Medical Expense Benefits selected by the Insured apply. The 24-Hour Accident Coverage

 

excludes students participating in high school interscholastic tackle football or as stated for in the Application. Each Insured who

 

pays the additional premium required for this benefit is insured under this provision. Insurance coverage is provided, 24-Hours

 

per day. Provides coverage during the weekends and vacation periods including the entire summer. Students are protected

 

while at Home or away. Coverage starts on the date of premium receipt by the Plan Administrator (but not before the start of the

 

school year). It ends when school reopens for the following school year. All provisions of the Policy, including all Coverage and

 

Limitations, Maximums and Exclusions, apply to Insureds covered under this provision.

 

OPTIONAL INTERSCHOLASTIC FOOTBALL COVERAGE

 

Coverage and Limitations stated for Medical Expense Benefits selected by the Insured apply. Each Insured who pays the

 

additional premium required for this benefit is insured under this provision. Travel is also covered when going directly and

 

uninterruptedly to and from the practice and competition. Ninth graders who play with 9

 

 

 

th graders only are not charged for

 

football coverage. Their School-Time or 24-Hour coverage will apply if purchased. Additional premium is required by the Insured

 

for this coverage. All other provisions of the Policy, including all Coverage and Limitations, Maximums and Exclusions, apply to

 

Insureds covered under this provision.

 

OPTIONAL 24-HOUR ACCIDENT DENTAL COVERAGE

 

Injury must be treated within 60 days after the accident occurs. Medical Expense Benefits are payable within 60 days after the

 

date of Injury. The maximum eligible expenses payable per covered Injury is $25,000. In addition, when the dentist certifies that

 

treatment must be deferred until after the Benefit Period, deferred benefits will be paid to a maximum of $1,000. Each Insured

 

who pays the additional premium required for this benefit is insured under this provision. Coverage starts on the date of premium

 

receipt by the Plan Administrator, but not before the start of the school year. It ends when school reopens for the following

 

school year. This provision covers Accidents occurring anytime and anywhere. The Insured must be treated by a legally qualified

 

dentist who is not a member of the Insured’s Immediate Family for Injury to teeth. The Company will then pay the Reasonable

 

Expense which is Medically Necessary. Coverage is limited to treatment of sound, natural teeth. The maximum benefit payable

 

under this provision is stated in the Policy. All other provisions of the Policy, including all Coverage and Limitations, Maximums

 

and Exclusions, apply to Insureds covered under this provision.

 

DEFINITIONS

 

Hospital

 

 

 

 

 

means an institution that meets all of the following: 1) it is licensed as a Hospital pursuant to applicable law; 2) it is

 

primarily and continuously engaged in providing medical care and treatment to sick and injured persons; 3) it is managed under

 

the supervision of a staff of medical doctors; 4) it provides 24-hour nursing services by or under the supervision of a graduate

 

registered nurse (R.N.); 5) has permanent facilities that are

 

 

 

equipped and operated mainly for the purpose of performing

 

surgical procedures, unless facility is primarily of a rehabilitative nature, if such rehabilitation is specifically for treatment of

 

physical disability

 

 

 

; and 6) it charges for its services.

 

Hospital also means a psychiatric hospital as defined by Medicare. It must be eligible to receive payments under Medicare. A

 

Hospital is mainly not a place for rest, a place for the aged, a place for the treatment of drug addicts or alcoholics, or a nursing

 

home.

 

Injury

 

 

 

 

 

means bodily injury caused by an Accident. The Injury must occur while the Policy is in force and while the Insured is

 

covered under the Policy. The Injury must be sustained as stated on the face page of the Policy, except where specifically stated

 

otherwise in the Policy.

 

Reasonable Expense

 

 

 

 

 

means the average amount charged by most providers for treatment, service or supplies in the

 

geographic area where the treatment, service or supply is provided. Such services and supplies must be recommended and

 

approved by a Physician.

 

HOSPITAL AND PROFESSIONAL SERVICES

 

The Company will pay Reasonable Expenses incurred for a covered Injury. The Injury must be treated within the number of days

 

stated in the Schedule of Benefits. Services must be given: (1) by a Physician; (2) for Medically Necessary treatment; and (3)

 

within the time limit stated in the Schedule of Benefits. Benefits are paid to the maximum stated in the Schedule of Benefits for

 

any one Injury for Reasonable Expenses which are in excess of the Deductible. Benefits under this provision are subject to all

 

other provisions of the Policy, including all Coverage and Limitations, Maximums and Exclusions.

 

COUNSELING BENEFIT

 

If as a result of an Act of Violence an Insured is killed while on School Property, the Company will pay a lump sum of $5,000 for

 

Counseling Services. The lump sum benefit will be paid directly to the covered School or to the hospital or person rendering

 

such services after the commencement of Counseling Services. The company will not pay for any expense for loss due to

 

participation in a riot or insurrection. All provisions in this Policy apply to this coverage.

 

Definitions for the purpose of this section:

 

 

 

Act of Violence means an Injury inflicted by a person with malicious intent to cause

 

bodily harm.

 

 

 

Counseling Services means psychiatric/psychological counseling that is under the care, supervision, or direction

 

of a professional counselor or Physician and essential to assist the Insured in coping with the Act of Violence. Counseling

 

Services must be: a) Arranged by the covered School; b) Provided to a living Insured due to an Act of Violence; and c) Received

 

during the Benefit Period shown on the Schedule of Benefits.

 

 

 

School Property means the physical location of the covered

 

School or the location of an activity or event approved by the covered School.

 

EXCESS COVERAGE

 

The Company will pay Reasonable Expenses that are not recoverable from any Other Plan. The Company will determine the

 

amount of benefits provided by Other Plans without reference to any coordination of benefits, non-duplication of benefits, or

 

similar provisions. The amount from Other Plans includes any amount, to which the Insured is entitled, whether or not a claim is

 

made for the benefits. This Blanket Student Accident Insurance is secondary to all other policies.

 

This provision will not apply if the total Reasonable Expenses incurred for Hospital and Professional Services Benefits are less

 

than the amount stated in the Schedule of Benefits under Excess Coverage Applicability.

 

ACCIDENTAL DEATH, DISMEMBERMENT, OR LOSS OF SIGHT

 

When a covered Injury results in any of the Losses to the Insured which are stated in the Schedule of Benefits for Accidental

 

Death, Dismemberment, or Loss of Sight then the Company will pay the benefit stated in the schedule for that Loss. The Loss

 

must be sustained within 365 days after the date of the Accident.

 

The maximum benefit payable under this provision is stated in the Schedule of Benefits under Maximums and Benefit Period: 1)

 

Life 2) Both Hands or Both Feet or Sight of Both Eyes; 3) Loss of One Hand and One Foot; 4) Loss of One Hand and Entire

 

Sight of One Eye; 5) Loss of One Foot and Entire Sight of One Eye; 6) Loss of One Hand or Foot; 7) Loss of Sight in One Eye;

 

8) Loss of Speech; 9) Loss of Hearing (both ears); 10) Loss of Speech and Hearing (both ears); 11

 

 

 

) Loss of Thumb and

 

Index Finger of the Same Hand.

 

Half of the maximum benefit will be paid for the Loss of one Hand, one Foot or the Sight of one eye.

 

Loss of Hand or Foot means the complete Severance through or above the wrist or ankle joint. Loss of Sight means the total,

 

permanent Loss of Sight in One Eye. The Loss of Sight must be irrecoverable by natural, surgical or artificial means.

 

 

 

Loss of

 

Speech means total and permanent loss of audible communication which is irrecoverable by natural, surgical or artificial

 

means. Loss of Hearing means total and permanent loss of ability to hear any sound in both ears which is irrecoverable

 

by natural, surgical or artificial means.

 

 

 

Loss of Thumb and Index Finger of the Same Hand means complete Severance

 

through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). Severance

 

means the complete separation and dismemberment of the part from the body.

 

If the Insured suffers more than one of the above covered losses as a result of the same Accident the total amount the Company

 

will pay is the maximum benefit.

 

Benefits paid under this provision will be paid in addition to any other benefits provided by the Policy.

 

Benefits under this provision are subject to all other provisions of the Policy, including all Coverage and Limitations, Maximums

 

and Exclusions.

 

EXCLUSIONS

 

No Benefits are payable for Hospital and Professional Services for the following: 1) Injuries which are not caused by an

 

Accident; 2) Treatment for hernia, regardless of cause, Osgood Schlatter’s disease, or osteochondritis; 3) Injury sustained as a

 

result of operating, riding in or upon, or alighting from a two-, three-, or four-wheeled recreational motor vehicle or snowmobile;

 

4) Aggravation, during a Regularly Scheduled Activity, of an Injury the Insured suffered before participating in that Regularly

 

Scheduled Activity, unless the Company receives a written medical release from the Insured’s Physician; 5) Injury sustained as

 

a result of practice or play in interscholastic tackle football and/or sports, unless the premium required under the Football and/or

 

Sports Coverage provision has been paid; 6) Any expense for which benefits are payable under a Catastrophic Accident

 

Insurance Program of the State Interscholastic Activities Association; 7) Treatment performed by a member of the Insured’s

 

Immediate Family or by a person retained by the School; 8) Injury caused by declared or undeclared War or acts of War;

 

suicide, while sane or insane; violating or attempting to violate the law; the taking part in any illegal occupation; fighting or

 

brawling except in self defense; being legally intoxicated or under the influence of alcohol as defined by the laws of the state in

 

which the Injury occurs; or being under the influence of any drugs or narcotic unless administered by or on the advice of a

 

Physician; 9) Medical expenses for which the Insured received benefits under any (a) Workers’ Compensation act; or (b)

 

mandatory no-fault automobile insurance contract; or similar legislation; 10) Expense incurred for treatment of

 

temporomandibular joint dysfunction and associated myofacial pain; and 11) Expenses incurred for experimental or

 

investigational treatment or procedures.

 

NOTICE OF CLAIM

 

Written notice of claim must be given to the Company within 90 days after the occurrence or commencement of any loss

 

covered by this policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the Named Insured to the

 

Company, with information sufficient to identify the Named Insured shall be deemed notice to the Company. Written proof of

 

loss must be furnished to the Company at its said office within 90 days after the date of such loss.

 

In the event of an Accident, students should:

 

1. Secure treatment at the nearest medical facility of their choice.

 

2.

 

 

 

If you have other insurance, submit your claim to your other insurer. When you receive the explanation of benefits

 

notice from your primary carrier, send it to us.

 

3. Obtain a receipt (if payment of any bills were made) and itemized copy of charges from the provider of medical services and

 

send copies of their itemized bills, primary carrier explanation of benefits and the fully completed and

 

 

 

signed accident claim

 

form to the claims office – mail all correspondence to WEB-TPA, P.O. Box 2415, Grapevine, TX 76099-2415.

 

4.

 

 

 

Call 1-866-975-9468 with any Claims questions.

 

National Representative

 

Stevens Point, WI 54481

 

Phone: (800) 727-7642 Fax: (715) 344-6126

 

information@specialmarkets.com

 

specialmarkets.com

 

IMPORTANT NOTICE – THE POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS.

 

This brochure has been designed to illustrate the highlights of this insurance and it does not include all coverage

 

details. All information in this brochure is subject to the provisions of Policy Form COL-11(FL), underwritten by

 

Gerber Life Insurance Company. If there is any conflict between this brochure and the Policy, the Policy will

 

prevail.

 

Note: Please see the Master Policy for complete and individual state details.

 

SCHEDULE OF BENEFITS

 

Coverage for Injuries due to Accidents only

 

Maximum Benefit: Plan “Basic” Plan “A” Plan “B” Plan “C”

 

School-Time Option $25,000 $25,000 $25,000 $25,000

 

24-Hour Option $25,000 $25,000 $25,000 $25,000

 

Football Option $25,000 $25,000 $25,000 $25,000

 

Injuries Involving Motor Vehicles $25,000 $25,000 $25,000 $25,000

 

Death Benefit/Single Dismemberment $10,000 $10,000 $10,000 $10,000

 

Double Dismemberment $20,000 $20,000 $20,000 $20,000

 

Loss Period for Medical Benefits

 

 

 

 

 

Treatment must begin within 90 days from the date of Injury

 

Benefit Period for Medical and AD&D/Loss of Sight Benefits

 

 

 

 

 

1 Year 1 Year 1 Year 1 Year

 

Excess Coverage Applicability

 

 

 

 

 

Full Excess Full Excess Full Excess Full Excess

 

Hospital/Facility Services - Inpatient

 

Hospital Room and Board (Semi-Private Room Rate) 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Hospital Intensive Care 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Inpatient Hospital Miscellaneous 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Hospital/Facility Services - Outpatient

 

Outpatient Hospital Miscellaneous

 

(Except physician services and x-rays paid as below) 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Hospital Emergency Room 100% RE* / $100 Max. 100% RE* / $200 Max. 100% RE* / $400 Max. 100% RE* / $600 Max.

 

Free-standing Ambulatory Surgical Facility 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Day Surgery Miscellaneous 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Physician's Services

 

Surgical 100% RE* / $750 Max. 100% RE* / $1,500 Max. 100% RE* / $3,000 Max. 100% RE* / $4,500 Max.

 

Assistant Surgeon 25% of Surgical Benefits. 25% of Surgical Benefits 25% of Surgical Benefits 25% of Surgical Benefits

 

Anesthesiologist 25% of Surgical Benefits 25% of Surgical Benefits 25% of Surgical Benefits 25% of Surgical Benefits

 

Physician's Non-surgical Treatment (Except as below) 100% RE* / $35 per day 100% RE* / $50 per day 100% RE* / $100 per day 100% RE* / $150 per day

 

Physician's Outpatient Treatment in connection with Physical Therapy

 

and/or Spinal Manipulation $35/Visit / 10 Visits Max. $50/Visit / 10 Visits Max. $100/Visit / 10 Visits Max. $150/Visit / 10 Visits Max.

 

Other Services

 

Registered Nurses' Services 100% RE* 100% RE* 100% RE* 100% RE*

 

Prescriptions - outpatient 100% RE 100% RE* 100% RE* 100% RE*

 

X-rays, includes interpretation - outpatient 100% RE* / $200 Max. 100% RE* / $250 Max. 100% RE* / $400 Max. 100% RE* / $600 Max.

 

Diagnostic Imaging (MRI, CAT Scan, etc)

 

includes interpretation - outpatient 100% RE* / $400 Max. 100% RE* / $500 Max. 100% RE* / $800 Max. 100% RE* / $1,200 Max.

 

Ground Ambulance 100% RE* / $350 Max. 100% RE* / $500 Max. 100% RE* / $1,000 Max. 100% RE* / $1,500 Max.

 

Air Ambulance 100% RE* / $350 Max. 100% RE* / $500 Max. 100% RE* / $1,000 Max. 100% RE* / $1,500 Max.

 

Durable Medical Equipment

 

(includes Orthopedic Braces & Appliances) 100% RE* / $200 Max. 100% RE* / $250 Max. 100% RE* / $400 Max. 100% RE* / $600 Max

 

Dental Treatment to sound, natural teeth due to covered injury. 100% RE* / $200 Max. 100% RE* / $250 Max. 100% RE* / $400 Max. 100% RE* / $600 Max.

 

(When the dentist certifies that treatment will continue beyond the 52 week benefit Period the Company will continue to cover the incurred expenses at 100% RE*; provided such

 

expenses are incurred within 2 years from the date of the first treatment for Injury)

 

Replacement of eyeglasses, hearing aids, contact lenses,

 

if medical treatment is also received for the covered injury. 100% RE* / $200 Max. 100% RE* / $250 Max. 100% RE* / $400 Max. 100% RE* / $600 Max.

 

Heart or Circulatory Malfunction 100% RE* / $10,000 Max. 100% RE* / $10,000 Max. 100% RE* / $10,000 Max. 100% RE* / $10,000 Max.

 

*

 

 

 

RE means Reasonable Expense

 

 

 

2014 – 2015 STUDENT ACCIDENT INSURANCE COVERAGE

 

OPTIONAL SCHOOL TIME ACCIDENT COVERAGE -

 

 

 

 

 

Insurance coverage is provided for covered Injuries incurred during the hours and days when school is in session and while attending or participating

 

in school sponsored and supervised activities on or off school premises. Includes participation in: Interscholastic Sports (if premium paid for), excluding Senior High (participating with grades 10-12)

 

interscholastic tackle football; Summer Recreation Activities sponsored by the school; One-Day School Field Trips (excludes trips of 7 or more consecutive nights) and School Sponsored Religious

 

Activities. Coverage is provided for 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 their home

 

premises and the school or the site of a covered activity.

 

Annual Premium: Plan “Basic” Plan “A” Plan “B” Plan “C”

 

Excluding all Senior High Sports $ 9.00 $12.00 $29.00 $45.00

 

Including all Sports Except Senior High Football $24.00 $27.00 N/A N/A

 

OPTIONAL 24-HOUR ACCIDENT COVERAGE -

 

 

 

 

 

Insurance coverage is provided around the clock, 24 Hours per day. Provides coverage during the weekends and vacation periods including the entire

 

summer. Students are protected while at Home or away, any place, any time, anywhere. Coverage is provided for participation in Interscholastic Sports (if premium paid for), excluding Senior High

 

(participating with grades 10-12) interscholastic tackle football.

 

Annual Premium: Plan “Basic” Plan “A” Plan “B” Plan “C”

 

Excluding all Senior High Sports $65.00 $77.00 $150.00 $225.00

 

Including all Sports Except Senior High Football $80.00 $92.00 N/A N/A

 

OPTIONAL FOOTBALL COVERAGE -

 

 

 

 

 

Covers Accidents occurring while participating in high school interscholastic tackle football practice or competition. Travel is covered when going directly and

 

uninterruptedly to or from such practice or competition as part of a group in transportation furnished or arranged by the Policyholder. Refer to benefits and limitations described inside this brochure. Optional

 

Football Coverage begins on the date of premium receipt and ends on the last day of practice or competition. Ninth Graders who play with 9

 

 

 

th graders ONLY are not charged extra for football coverage.

 

Their Optional School-Time or Optional 24-Hour Accident Coverage will apply if purchased.

 

Annual Premium: Plan “Basic” Plan “A”

 

Fall and Spring/Summer $75.00 $110.00

 

Spring/Summer $30.00 $39.00

 

(for new players who participate in spring/summer and not already insured under the Fall and Spring/Summer option)

 

OPTIONAL 24-HOUR DENTAL COVERAGE (Can be purchased separately or with other coverage) –

 

 

 

 

 

Insurance coverage is in effect 24 Hours a day. Injury must be treated within 60 days after the

 

Accident occurs. Benefits are payable within 12 months after the date of Injury. The maximum eligible expenses payable per covered Injury is $25,000. In addition, when the dentist certifies that treatment

 

must be deferred until after the Benefit Period, deferred benefits will be paid to a maximum of $1,000. The Student must be treated by a legally qualified dentist who is not a member of the student’s

 

Immediate Family for Injury to teeth. Coverage is limited to treatment of sound, natural teeth.

 

 

 

Annual Premium: $8.00

 

COVERAGE PERIOD –

 

 

 

 

 

Coverage under the Optional School-Time Accident Coverage, the Optional 24-Hour Accident Coverage and the Optional 24-Hour Dental Coverage starts on the date of premium

 

receipt but not before the start of the school year. Optional School-Time Accident Coverage ends at the close of the regular nine-month school term, except while the student is attending academic

 

classroom sessions exclusively sponsored and solely supervised by the School during the summer. Optional 24-Hour Accident and Dental Coverage ends when school reopens for the following school

 

year. Coverage is available under the plan throughout the school year at the premiums quoted

 

 

 

(no pro rata premiums available).

 

EXCESS COVERAGE PROVISION

 

 

 

 

 

The Company will pay Reasonable Expenses that are not recoverable from any Other Plan. The Company will determine the amount of benefits provided by Other

 

Plans without reference to any coordination of benefits, non-duplication of benefits, or similar provisions. The amount from Other Plans includes any amount, to which the Insured is entitled, whether or not

 

a claim is made for the benefits. This Blanket Student Accident Insurance is secondary to all other policies. This provision will not apply if the total Reasonable Expenses incurred for Hospital and

 

Professional Services Benefits are less than the amount stated in the Schedule of Benefits under Excess Coverage Applicability.

 

MEDICAL BENEFITS

 

 

 

 

 

When a covered Injury to a student results in 1) treatment by a legally qualified Physician or surgeon (other than a member of the immediate family or person retained by the school)

 

or 2) Hospital confinement, and treatment begins within 90 days from the date of Injury, the Company will pay the benefit as shown in the Schedule of Benefits, subject to the Excess Coverage Provision

 

above. 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

 

stated in the Medical Benefit plan purchased. Expenses incurred after one year from the date of Injury are not covered, even though the service is a continuing one, or one that is necessarily delayed

 

beyond one year from the date of Injury.

 

GERBER LIFE INSURANCE COMPANY

1311 Mamaroneck Avenue, White Plains, New York 10605

 

Blanket Accident Insurance Application

 

Name of Policyholder TAYLOR COUNTY SCHOOL DISTRICT                                            Policy Number                                                     

(as it should appear on the Policy)

 

Mailing Address 318 NORTH CLARK STREET   PERRY, FL. 32347                                                                                                                        

(City)                                       (State)                                     (Zip Code)

 

Insurance Contact Name Chris Olson                                                       Title                                                                                                  

 

Phone 850-838-2503                                          Fax                                                           Email Address chris.olson@taylor.k12.fl.us                

 

Policy Effective Date* 08/01/2014                                                    Policy Expiration Date 08/01/2015                                                                

(*This will be the effective date if enrollment form and premium are received)

 

Covered Activities and Rates

 

Optional Coverages – Plan “Basic”, Plan “A”, Plan “B” and Plan “C” Only

(Paid for by the Student or Parent per year. A link will be provided for on-line enrollment)

 

¨ School Time Excluding All Senior High Sports  ¨ School Time Including all Sports Except Senior High Football**

¨ 24Hour Excluding All Senior High Sports   ¨ 24Hour Including all Sports Except Senior High Football**

¨ Football Fall and Spring/Summer** ¨ Football Spring/Summer**

¨ Dental

 

**Plan “B” and Plan “C” are not available under these coverages.

 

First Day School Activities:  08/18/2014               TO 06/02/2015               Football Effective: 08/04/2014               TO                                   

 

 

Please mail application to:     Fowinkle School Insurance Agency

120-53rdAve.W Bradenton, FL 34207

 

We hereby enroll with Gerber Life Insurance Company for the plan(s) of insurance selected. We understand that insurance will be in force if this application is accepted by the Company, and the required premium is received by the Company when due. We represent that the information contained in this application is true and correct and forms the basis of the requested insurance.

 

 

                              

Signature of Official Authorized to Contract for the Policyholder               Printed Name                                                         Date Signed

 

 

 

 

                                                                         

     
     

Local/Regional Representative of Policyholder

     
     

                                    

     
     

Agency       Name:   Moore Fowinkle Schoroer Agency                        

     
     

                                    

     
     

Representative Name: ROBERT W. FOWINKLE           

     
     

                                    

     
     

Address:

     
     

                                    

     
     

120-53rd Avenue West

     
     

                                    

     
     

City,       State, Zip:   Bradenton, FL 34207                               

     
     

                                    

     
     

Phone Number: 800-541-8256                                                     

     
     

                                    

     
     

Email Address: schoolinsuranceagency@verizon.net                                                                                                

     
     

                                    

     
     

Signature: Robert W. Fowinkle                                                            

     

(Policyholder Representative)

     
     

                                    

     
     

Date: 05/06/2014                                                               

     
     

                                    

     
     

License       Identification Number: A088216                     

     
     

     

 


FraudStatement

 

 

 

GENERAL FRAUD STATEMENT: 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.

 

 

 

For residents of Arkansas, Louisiana and 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.

 

 

 

For residents of 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.

 

 

 

For residents of the 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.

 

 

 

For residents of 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.

 

 

 

For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

 

 

 

For residents of Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

 

 

 

For residents of Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

 

 

For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

 

 

 

For residents of 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.

 

 

 

For residents of 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 for each such violation.

 

 

 

For residents of 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.

 

 

 

For residents of 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.

 

 

 

For residents of 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.

 

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