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Two School-Approved Plans to help pay doctor, hospital and dental bills.

24-Hour Coverage

YOUR BEST BUY!

Around-the-clock accident coverage for your child anywhere in the world. Protection during vacations, weekends and school days.

24-Hour Coverage is your best buy because it is not limited to school connected accidents but also covers accidental injury at home or away. ANY COVERED ACTIVITY-ANYTIME ANYWHERE. Continuous protection from the effective date to the opening of the next school term.

At School Only Coverage

Insurance coverage for the hours and days when school is in session and while attending school sponsored and supervised activities including
religious services;

• During school year • On the school premises
• Travel to and from school • School supervised activities
• Class trips

These coverages are subject to the terms and conditions stated in the policy.

Questions & Answers

QIs this policy primary or secondary coverage?
A This policy is primary. Benefits are paid regardless of any other insurance you may have.
Q May we purchase the policy any time during the year?
A Yes, but you pay the same rate for the balance of the year as you would have paid for the entire
year. The earlier you purchase the policy the more days of coverage your student will have.
Q Will this policy pay if our other insurance has a deductible?
AYes, benefits are paid without regard to other insurance.

$50,000 OPTIONAL ACCIDENT DENTAL TREATMENT BENEFIT

For an additional premium of $7.50 per person, added to the cost of the basic plan selected, or a premium of $14.00 without student coverage, the policy may be extended to include an Accident Dental Treatment benefit for treatment of natural teeth within two years from the date of accident, not to exceed $50,000 in the aggregate, provided the first treatment is rendered within 100 days from the date of injury.
The additional benefit will provide payment for all usual and reasonable expenses for examination, diagnosis, and X-ray; restorative treatment, endodontics, and oral surgery (not including periodontics); plus a maximum of $600 for dental prosthesis toward the cost of a bridge, denture or partial denture, providing such expense is caused by a covered accident. If we have proper certification that treatment must be deferred until after the two-year claim period (from the date of the accident), a maximum of $250.00 (in addition to charges incurred and work performed within the two-year claim period) will be paid in lieu of all other dental benefits, and must be incurred by age 21.

CLAIM PROCEDURE

Simplified claim forms are available through the school or from the Administrator. Attach itemized bill(s) to the completed claim form and mail to the Administrator or the address shown on the claim form. Claims for benefits must be filed within 90 days from date of accident. Only one claim form necessary per accident.

PERIOD OF COVERAGE

Persons applying for coverage shall be covered as of the date of premium receipt, but in no event prior to the opening of school activities. Coverage ends at close of the regular school term, except under 24-hour coverage, which continues until school reopens for the following fall term.

You may enroll at any time, but premiums are not prorated.

ENROLL EARLY FOR THE MAXIMUM PERIOD OF COVERAGE.

HOW TO ENROLL

  1. Decide whether you want the 24-Hour Accident Protection, SchoolTime Plan, or Dental Plan.
  2. Fill out enrollment envelope, enclose check or money order payable to the Company for the correct amount.
  3. Return by mail to AG Administrators, Inc. Your cancelled check or money order stub will be your receipt and confirmation of payment. (Please write student’s name and school name on your check).

MAKE CHECKS PAYABLE TO:
UNITED STATES FIRE
INSURANCE COMPANY

C/O AG Administrators, Inc.
P.O. Box 979 • Valley Forge, PA 19482

Print application
Click to Print the Application Above

STUDENT ACCIDENT INSURANCE

BENEFIT PROGRAM
FOR MEDICAL AND DENTAL EXPENSES, up to $250,000.00 shall be payable for the following treatment, care and services within 52 weeks (1 year) after the date of accident, provided that the first medical or dental attention is received within ninety (90) days after the date of the accident. The first $15,000.00 is based on the benefits below, and the remaining expenses will be paid on a blanket basis for the usual and reasonable expenses incurred up to an aggregate maximum of $250,000.00 for any one covered accident.

  • MEDICAL TREATMENT– by a person licensed for the practice of medicine, osteopathy, dentistry, chiropractic, optometry, podiatry or physical therapy, or other legally licensed provider acting within the scope of his license for an injury not requiring surgery, or other medical treatment, not to exceed the usual and reasonable charge for such visits in the area rendered, Non-surgical doctor’s charges in the emergency room limited to $70.00.
  • CONSULTANT’S, SPECIALIST’S AND SECOND OPINION FEES When requested by the attending physician, not to exceed $150.00 in the aggregate.
  • SURGERY The usual and customary charges in the area, not to exceed allowances under the 1974 Revised California Relative Value Studies; 5th Edition, using a conversion factor of $170.00 per unit. Payment for anesthetists shall not exceed 40% of the allowances for surgery.
  • HOSPITAL CARE AND SERVICES when the insured is confined as a resident patient for at least 24 hours, the usual, and reasonable and customary charge for semiprivate room, not to exceed $300.00 per day, plus up to $3,000.00 total per accident for necessary ancillary expenses, including X-rays, incurred in the treatment while hospital confined.
  • OTHER HOSPITAL EXPENSES if the insured is not confined as a resident patient for at least 24 hours, the Company will pay the usual and customary charge in the area, not to exceed $400.00 in the aggregate. If outpatient surgery is required, the maximum benefit is increased to $1,500.00.
  • INTENSIVE CARE when insured is confined to a hospital Intensive Care Unit as required by the attending physician-$700.00 per day in addition to benefits provided in Covered Charge number 4, not to exceed 10 days for any one covered accident.
  • X-RAYS when not hospital confined, the usual, reasonable and customary charge in the area, not to exceed allowances under the 1974 Revised California Relative Value Studies; 5th Edition, using a conversion factor of $20.00 per unit. When no fracture is demonstrated, limited to $400.00.
  • NURSE SERVICE upon recommendation of the attending physician, the usual, reasonable and customary charge provided by a registered graduate nurse (R.N.), during a period of hospital confinement.
  • PROFESSIONAL AMBULANCE SERVICE usual, reasonable and customary charge in the area to and from the hospital up to a maximum of $300.00.
  • DENTAL TREATMENT of one or more natural teeth, not to exceed $200.00 for each injured tooth, including charges for braces, crowns, jackets, fillings, bridges and root canal therapy.
  • DRUGS AND MEDICATION administered in a doctor’s office or by prescription, not to exceed usual, reasonable and customary charge.
  • EYEGLASSES replacement of broken eyeglasses, broken frames or broken lenses resulting from a covered accident not to exceed in the aggregate $100.00 for any one covered accident. Routine refractions or routine eye examinations are not covered under this policy.
  • ORTHOPEDIC APPLIANCES up to $500.00 when ordered by an attending physician.
  • OTHER MEDICAL TREATMENT including adjustment, manipulation or massage in any form, diathermy, heat treatment in any form, or cybex evaluation, provided that not more than $50.00 shall be payable per day regardless of the number of or types of treatment provided, nor more than a total maximum benefit of $500.00 for any one covered accident.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

A. If injury shall result in the death of the Insured, the Company will pay the
Accidental Death Benefit of $2,500.00.
B. If the Insured by reason of injury shall sustain any of the following specific
losses within one hundred (100) days after the date of accident, the Company
will pay for loss of:
Both hands or both feet or both eyes …………………….. $20,000.00
(The Double Dismemberment Benefit)
One hand and one foot, one hand and one eye,
or one foot and one eye ………………………………… $10,000.00

One hand or one foot …………………………………… $ 7,500.00
One eye ………………………………………………. $ 5,000.00
Loss shall mean in regard to hand or hands or foot or feet, actual severance
through or above the wrist or ankle, loss of eye or eyes shall mean the
irrecoverable loss of the entire sight thereof.
No more than one amount, the amount equal to the largest benefit payable,
will be paid under A and B if more than one loss is incurred as the result of the
same accident.

THIS POLICY DOES NOT COVER, nor is any premium charged for: Injuries resulting from participating in interscholastic senior high football in any form, including practice sessions or travel to and from such activities or practice, intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane; commission or attempting to commit a felony or an assault; commission of or active participation in a riot or insurrection; bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding; declared or undeclared war or act of war; flight in, boarding or alighting from an aircraft or any craft designed to fl y above the earth’s surface except as a fare-paying passenger on a regularly scheduled commercial airline; travel in or on any on-road and off-road motorized vehicle that does not require licensing as a motor vehicle; sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, including exposure, whether or not accidental, to viral, bacterial or chemical agents except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food; the covered person being legally intoxicated as determined according to the laws of the jurisdiction in which the covered accident occurred; voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a physician and taken in accordance with the prescribed dosage; injuries compensable under workers’ compensation law or any similar law; cosmetic surgery, except for reconstructive surgery needed as the result of a covered injury; services or treatment provided by persons who do not normally charge for their services, unless there is a legal obligation to pay. In addition, benefits will not be paid for services or treatment rendered by any person who is employed or retained by the policyholder or living in the covered person’s household; a parent, sibling, spouse or child of either the covered person or covered person’s spouse; the Covered Person.

IMPORTANT – KEEP THIS BROCHURE AS A SUMMARY OF BENEFITS UNDER YOUR SCHOOL ACCIDENT INSURANCE. COMPLETE PROVISIONS PERTAINING TO THIS PLAN ARE CONTAINED
IN MASTER POLICY ON FILE AT SCHOOL.