C
H
O
O
P
2024-2025STUDENT ACCIDENT INSURANCE PLANS

■ Accidents happen! When they happen to your child, someone must pay the bills.

■ Here are Accident only insurance plans to help cover your child either 24 hours a day (24-Hour Plan) or while in school (School-Time Plan). ■ These plans provide benefits to help meet the cost of medical and Hospital expense.
■ If you have other insurance, these plans can help offset the deductibles and coinsurance for those plans. ■ If you have no other insurance, these plans will provide basic coverage.
■ Any benefits payable by the Policy as a result of medical, surgical, dental, Hospital or nursing service will be paid directly to the Hospital or person rendering such service unless proof of payment in full is provided.

24-HOUR S TIME L

✓	✓

✓	✓ ✓

✓	✓

✓	✓

✓

✓

IMPORTANT PROTECTION FACTS

Becomes effective the date premium payment is received by Guarantee Trust Life Insurance Company (GTL), its representatives or school officials (but not prior to the opening day of school). Students participating in preschool practice or play for interscholastic sports sanctioned by the Ohio High School Athletic Association will be covered as of the date of actual premium payment but only while engaged in actual practice or game sessions. Other aspects of coverage will not start sooner than the first date of regular school session.

Provides coverage during the hours that school is in regular session. Provides 24-Hour-A-Day protection.
m
n
d
o
f
r
e
g
u
l
a
r
s
c
h
o
o
l
s
e
s
s
i
o
n
s
erovides coverage during the ti. e necessary for travel between the insured’s home and the beginning or

C
o
v
e
r
a
g
e
i
s
a
l
s
o
p
r
o
v
Provides coverage while participating in (or attending) activities organized, sponsored and supervised by the school. ided for travel directly to and from such activities in a Designated Vehicle furnished by the school.

C
o
v
e
r
a
g
e
e
x
p
i
r
e
s
a
t
t
h
e
c
l
o
s
e
o
f
a
s
s
r
o
o
m
s
e
s
s
i
o
n
s
a
r
e
e
x
c
l
u
s
i
v
e
l
y
s
p
o
n
s
o
r
e
d
a
n
d
s
o
l
e
l
y
s
u
p
e
r
v
i
s
e
d
b
y
t
h
e
s
c
h
o
o
l
;
h
o
w
e
v
e
r
,
n
o
c
o
v
e
r
a
g
e
w
i
l
l
b
e
p
r
o
for credit in the summer, when cl the regular school term. (Coverage will be extended while attending academic classes vided for travel to and from classes).

Coverage continues without interruption all summer until school re-opens for the following term.

Optional Football Only Accident Coverage begins on the date of premium receipt by GTL, its representatives or school officials, but not prior to the first official date of practice; and continues through the date of the last official game of the current season including playoffs.
Football premium covers football only.

To file a claim: Report accidents to the school. Forms will be furnished through the principal’s office (during vacation time contact the administrators of the plan). Complete proof of loss and accumulated bills must be received by Guarantee Trust Life Insurance Company within 90 days.

24-HOUR-A-DAY ACCIDENT COVERAGE

24-Hour-A-Day Protection for each Covered Accident

Helps protect your child for the entire school year and extends throughout the summer - right up to the day school opens.

Your child’s coverage is good WORLDWIDE, 24-HOURS-A-DAY. This includes covered accidents:

✎ At home	✎ At play	✎ At school	✎ On vacation	✎ Scouting, camping etc.	✎ During covered travel ✎ While engaged in sports, except those specifically excluded or for which optional coverage is required*
*See OPTIONS for available optional sports coverage, if any.

SCHOOL-TIME ACCIDENT COVERAGE

Helps protect your child while attending regular school sessions. Includes coverage for travel directly to and from your residence to attend regular school sessions for travel time required, but not more than one hour before or after regular classes. Travel time on the school bus is extended for any additional time needed. In addition, coverage is provided while participating in (or attending) covered activities exclusively organized, sponsored and solely supervised by the school and school employees, including travel directly to and from the activity in a Designated Vehicle furnished by the school and supervised solely by school employees. Optional coverage may be required for interscholastic sports. See OPTIONS for available optional sports coverage, if any.

TERMINATION OF POLICY/CERTIFICATE OF COVERAGE: The Policy is issued for the agreed upon term of coverage and is non-renewable. Coverage will terminate at the earlier of: (1) the date the Policy terminates; or (2) the date the Insured ceases to be a member of the Policyholder’s sports teams; or (3) the last day of regularly scheduled sports activity; or (4) the date the Insured ceases to be an Eligible Person; or (5) the end of the period for which any applicable premium has been paid. We have the right to terminate the coverage of any Insured who submits a fraudulent claim under the Policy.

K-12-OH-24-25	1

O
O
O
What’s Covered? Up to $25,000.00 as described under Coverage and Benefits for:

■ ACCIDENTS OCCURRING WHILE COVERAGE IS IN FORCE

■ LOSS FROM ACCIDENTAL BODILY INJURY RESULTING DIRECTLY AND INDEPENDENTLY OF ALL OTHER CAUSES ■ COVERED MEDICAL EXPENSE WHICH BEGINS WITHIN 30 DAYS OF THE ACCIDENT AND IS INCURRED WITHIN
52 WEEKS OF THE ACCIDENT

COVERAGE AND BENEFITS

BENEFITS PER INJURY
		HIGH PTION
	
IMAGING PROCEDURES
	Including X-rays and interpretation
	
$100
	
$200
	
MRI/CAT Scan
		$125
	
$250
	
ORTHOPEDIC APPLIANCES
	
Furnished by the Hospital
	
$100
	
$200
	
DENTAL TREATMENT
	For Injury to Sound, Natural Teeth, per tooth

Up to a maximum of

$600
	
$400

$1,200

ACCIDENTAL DEATH AND DISMEMBERMENT
Only one of these benefits, the largest, will be payable in addition to other benefits shown
	
Caused by an Injury and occurring within 365 days of the covered Accident
ACCIDENTAL DEATH DISMEMBERMENT
Loss of One Hand or One foot
Loss of the Entire Sight of Both Eyes
Loss of Both Hands or Feet

$2,000

$1,000

$1,000

$10,000

BENEFITS ARE PAYABLE UP TO THE DOLLAR AMOUNTS SPECIFIED BELOW

BENEFITS PER INJURY
	LOW PTION
	HIGH PTION
	
HOSPITAL ROOM AND BOARD AND GENERAL NURSING CARE
	
Per day
	
$150
	
$300
	
HOSPITAL MISCELLANEOUS EXPENSE
		
$1,000
	
$2,000
	
HOSPITAL EMERGENCY CARE
		
$150
	
$300
	
DOCTOR’S FEES FOR SURGERY
	
Limited to a maximum of
	
$1,500
	
$3,000

ANESTHESIA SERVICES
		
100% of Reasonable & Customary
	
AMBULANCE EXPENSE
		
$100
	
$200
	
DOCTORS’ VISITS Non-surgical Including
Physical Therapy
	
Per visit
	
$25
	
$50

Physical Therapy, per visit

Maximum number of visits per Injury
	
$25

3
	
$50

3

Injury means bodily Injury due to an Accident which results directly and independently of disease, bodily infirmity, or any other causes; solely, directly and independently of all other causes, results in medical expense; occurs after the effective date of the Insured’s coverage under the Policy; and occurs while the Policy is in force. All injuries sustained in any one Accident, including allrelated conditions and recurrent symptoms of these injuries, are considered a single Injury.

EXCLUSIONS - THE POLICY DOES NOT COVER: (1) Treatment, services or supplies which are not Medically Necessary; are not prescribed by a Doctor as necessary to treat an Injury; are Experimental/Investigational in nature; are received without charge or legal obligation to pay; are received from persons employed or retained by the Policyholder or any Family Member, unless otherwise specified; or are not specifically listed as Covered Charges in the Policy; (2) Intentionally self-inflicted Injury; (3) Injury sustained while violating or attempting to violate any duly enacted law; (4) Injury by acts of war, whether declared or not; (5) Injury received while traveling or flying by air, except as a fare paying passenger on a regularly scheduled commercial airline; (6) Injury covered by Worker’s Compensation or the Occupational Disease Law; (7) Treatment of illness, disease or infections, except infections which result from an accidental Injury or infections which result from accidental, involuntary or an unintentional ingestion of a contaminated substance; (8) Hernia, any type; (9) Injury sustained fighting or brawling, except in self-defense; (10) Suicide or attempted suicide; (11) Any penalty imposed by Other Valid and Collectible Insurance or Plan for failure to follow plan procedures; (12) Loss resulting from the use of any drug or agent classified as a narcotic, psycholytic, psychedelic, hallucinogenic, or having a similar classification or effect, unless prescribed by a Doctor; (13) Injury sustained while operating, riding in or upon, mounting or alighting from, any two, three or four- wheeled recreational motor/engine driven vehicle, snowmobile or all-terrain vehicle (ATV); (14) Injury sustained while participating in or practicing for senior high interscholastic tackle football including grade 9 if playing with grade 10 or above, including travel, unless optional coverage has been purchased; (15) Cosmetic or plastic surgery, except for reconstructive surgery on an injured part of the body; (16) Treatment in any Veteran’s Administration or federal Hospital, except if there is a legal obligation to pay; (17) Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs; (18) Dental treatment, except as specifically stated; (19) Services of an assistant surgeon or Doctor when surgery is performed; (20) Eyeglasses, contact lenses, routine eye exams or prescriptions therefore; (21) Prescription Drugs, crutches, braces, artificial limbs, etc., except as specifically stated.

Blanket Accident insurance is issued under Policy Form Series GP-2030, GP-2020 or GP-1200 by Guarantee Trust Life Insurance Company, Glenview, IL. The policy has exclusions, limitations, reductions of benefits, and conditions of eligibility and termination. Subject to state availability and variability. The Policy shall control in the event of any conflict between the Policy and this brochure. For complete details of coverage, please contact the agent administering the program.

Administered by: STUDENT PROTECTIVE AGENCY, 300 Coshocton Ave., Mount Vernon, OH 43050 • (800) 278-2544

Underwritten and claims paid by: GUARANTEE TRUST LIFE INSURANCE COMPANY (GTL), 1275 Milwaukee Ave., Glenview, IL 60025 • (800) 622-1993

K-12-OH-24-25	2

M
D
Y
N
O
O
T
A
2024-2025 SCHOOL YEAR ENROLLMENT FORM

ONE TIME ANNUAL PAYMENT
	
OPTIONS
	LOW	HIGH PTION           PTION
	
24-HOUR-A-DAY PLAN STUDENTS GRADES K-6 STUDENTS GRADES 7-12
	
❑ $79     ❑ $158 ❑ $91     ❑ $182
	
SCHOOL-TIME PLAN STUDENTS GRADES K-6 STUDENTS GRADES 7-12
	
❑ $23     ❑ $46 ❑ $37     ❑$74
	
OPTIONAL FOOTBALL COVERAGE
(GRADES 10-12, INCLUDING GRADE 9 IF PLAYING WITH 10-12) 2024 SEASON ONLY PER PLAYER

❑ $129 ❑ $258

OT L $	(PLEASEDONOTSENDCASH)
	
MAKE CHECK PAYABLE TO YOUR LOCAL AGENCY
	
NO REFUNDS ARE AVAILABLE

PLEASE PRINT CLEARLY

STUDENT’S
AME
FIRST NAME	MIDDLE INITIAL	LAST NAME

DATE OF BIRTH 		            MALE ❑	FEMALE ❑ ONTH                       AY                   EAR

SCHOOL DISTRICT	SCHOOL

GRADE 	 STUDENT’S ADDRESS 	

CITY	 STATE	ZIP

TELEPHONE #	 DATE OF ENROLLMENT 	

PARENT OR GUARDIAN’S EMAIL ADDRESS 	

NAME OF PARENT OR GUARDIAN (PLEASE PRINT)

SIGNATURE OF PARENT OR GUARDIAN

GA-15-KEF

✁

✍ ✍

PLEASE REMEMBER TO:

COMPLETE THE ENROLLMENT FORM AND CHECK THE PLAN AND OPTIONS YOU WANT.

MAKE YOUR CHECK OR MONEY ORDER (PLEASE DO NOT SEND CASH) FOR THE TOTAL ENCLOSED PAYABLE AS INDICATED.

MAIL THE ENROLLMENT FORM WITH YOUR CHECK OR MONEY ORDER TO:

*

STUDENT PROTECTIVE AGENCY 300 Coshocton Avenue
Mount Vernon, OH 43050

*

PLEASE NOTE: YOUR CANCELED CHECK IS YOUR RECEIPT. IF CANCELED CHECK IS NOT RECEIVED WITHIN 60 DAYS, PLEASE CONTACT YOUR PLAN ADMINISTRATOR.

K-12-OH-24-25	3

GUARANTEE TRUST LIFE INSURANCE COMPANY

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice tells you the different ways in which Guarantee Trust Life Insurance Company (“GTL”) may use and disclose your protected health information.

Among other things, the Health Insurance Portability and Accountability Act of 1996 (”HIPAA”) requires us to: 	Maintain the privacy of your protected health information.
	Provide notice of GTL’s legal duties and privacy practices with respect to your protected health information. 	Comply with the terms of the Notice currently in effect; and
	Provide you with this Notice.

You have a right to a paper copy of this Notice which will be provided to you upon request, even if this Notice was provided to you electronically.

Protected health information is information about you that is either held or transmitted by GTL, including demographic information, that identifies you (or can reasonably be used to identify you), and that relates to (i) your past, present or future physical or mental health or condition, (ii) the provision of health care to you, or (iii) the past, present or future payment for the provision of health care to you.

GTL understands that your protected health information is personal. We protect the privacy of that information in accordance with all federal and state privacy laws. If a use or disclosure of protected health information described within this Notice, which is required by federal law, is prohibited or materially restricted by state law, GTL will abide by the more stringent law.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION WITH YOUR WRITTEN AUTHORIZATION

GTL will not use or disclose your protected health information without your written authorization unless the use or disclosure is described within this Notice.

If you have given us written authorization to use or disclose your protected health information, you have the right to revoke that authorization, at any time, except to the extent that: (1) we have already acted in reliance on the authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, other law provides us with the right to contest a claim under the policy or the policy itself. Your written request to revoke an authorization should be directed to the address listed in the “Contact Information section below.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION

For Payment
We may request, use and disclose your protected health information, as needed, to determine or fulfill our responsibility for coverage and reimbursement for the provision of benefits under your health plan. This may include,
but is not limited to:
	determinations of eligibility of coverage (including coordination of benefits with other insurers or the
determination of cost sharing amounts) and adjudication or subrogation of health benefit claims; 	risk adjusting based on enrollee health status and demographic characteristics;
	billing, claims management, collection activities, obtaining payment under a contract for reinsurance;
	review of health care services with respect to medical necessity, coverage under a health plan, appropriateness
of care or justification of charges;
	utilization review activities, including pre-certification and pre-authorization of services, concurrent and
retrospective review of services;

PN02-1	1	Rev. 9/23/2013 (GTL)

	disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement: name and address; date of birth; social security number; payment history; policy/account number; and name and address of the health care provider and /or health plan.

For example, if your coverage has a coordination of benefits or other type of cost sharing provision, we may request and disclose protected health information about you to the other health plan carrier to determine the benefits due under the terms of your health plan with us. We may also contact your provider regarding your medical treatments and request details to determine if your coverage will pay for the treatments.

For Health Care Operations
We may use and disclose protected health information about you to support our business operations or the business operations of another insurer. These uses and disclosures are necessary to run the company and make sure all of our policyholders receive the services and benefits provided by their health plan coverage. These activities include, but are not limited to:

	underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, however, we are prohibited from using or disclosing genetic information about you for underwriting purposes;
	ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance);
	conducting or arranging for medical review, legal services, and auditing functions, including fraud investigations;
	business planning and development, such as conducting cost-management studies and analyses related to managing and operating the company, including development or improvement of methods of payment or coverage policies; and
	business management and general administrative activities of the company, including, but not limited to:
o customer service, including the provision of data analyses for policyholders, plan sponsors, or other customers;
o resolution of internal grievances; and
o the offer of an enhancement or upgrade to your existing coverage.

To Individuals Involved in Your Care
We may use and disclose your protected health information with your family, friends, personal representative or other individual you identify who are involved in your care or payment of a claim, unless you object. In addition, GTL may use and disclose your protected heath information to persons requesting such information if we can reasonably infer from the circumstances that you would not object to the disclosure. If you are not available to give your consent to a disclosure, or in an emergency, we may disclose your protected health information that is directly relevant to such person’s involvement in your care or payment for such care.

To Our Business Associates
We may also share your protected health information to an affiliate or business associate outside of GTL if they need protected health information in order to provide services to us (e.g., billing, claim adjudication and underwriting services.) Whenever an arrangement between GTL and a business associate involves the use or disclosure of your protected health information we will have a written contract that sets forth the terms regarding the use and disclosure of your protected health information and will require them to follow the HIPAA rules relating to the protection of protected health information.

For Other Uses and Disclosures
In addition to the above, we are permitted or required by law to use or disclose your protected health information, without your permission, for the following:
	Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
	Law Enforcement: We may release medical information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process. We may also disclose your protected health information if we suspect child abuse or neglect; we may also disclose your protected health information if we believe you to be a victim of abuse, neglect, or domestic violence.

PN02-1	2	Rev. 9/23/2013 (GTL)

	Health Oversight Activities: We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights with respect to the protected health information we maintain about you.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to us or to the business associate who maintains the medical information. If we would prefer to send you a summary or explanation of your medical information rather than the actual records, we may do so only with your consent and your agreement in advance to the fees imposed, if any. You may request your records be in paper or electronic format. We may charge a fee for the costs of copying, mailing or other supplies associated with mailing or copying your protected health information. We may deny your request in whole or in part to inspect and copy records in certain circumstances. If you are denied access to medical information, we will provide a written notice explaining the basis for the denial. You may also request that the denial be reviewed. Such request for review will either be approved or denied based on the grounds for denial. If the initial denial is reviewable, the person conducting the review will not be the same person who denied your original request. We will comply with the determination of the representative performing the review.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request and we retain the right to terminate an agreed to restriction. Such termination is only effective with respect to protected health information created or received after GTL has informed the individual of its termination of the restriction. Additionally requesting certain limitations may affect payment of benefits under your health plan. To request restrictions, you must make your request in writing to our Customer Service Department. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

You have the right to request and receive confidential communications. We will accommodate reasonable requests to send your protected health information to you at a different address, or other method of contact. We will not request an explanation from you as to the basis for the request. For example, you can ask that we only contact you at work or by mail. Requests for confidential communications must be made in writing, signed by you and sent to GTL. Your request must specify how or where you wish to be contacted.

You have the right to request an amendment of your protected health information. You may request an amendment of your health information contained in a designated record set for as long as the information is kept by GTL or any of our business associates. To request an amendment, you must send us your request in writing to the address included in the “Contract Information” Section below, giving details of your request and why you are making it. If we deny your request for amendment in whole or in part, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We will provide you with a copy of any such rebuttal. In certain cases, we may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the designated record set kept by us; (3) is not part of the information which you would be permitted to inspect and copy; or (4) is accurate and complete.

You have the right to receive an accounting of certain disclosures. You have the right to request an accounting of most disclosures of protected health information made by us during the six years prior to the date the accounting is requested, subject to certain exceptions. Your request must be in writing. If you request such an accounting more than once in a 12-month period, we may charge a cost-based reasonable fee.

You have the right to be notified following a breach of unsecured protected health information. You have the right to and will receive a notification of a breach of your unsecured protected health from GTL, or one of its business associates.
PN02-1	3	Rev. 9/23/2013 (GTL)

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint in writing to us at the address shown below in the “Contact Information” Section. You may also file a complaint in writing with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

THIS NOTICE IS SUBJECT TO CHANGE
We reserve the right to change the terms of this Notice and our privacy policies at any time. If we do, the new terms will be effective for all protected health information maintained by us, including protected health information received by GTL before the effective date of the new terms. If we do revise our privacy notice, a copy of the new notice will be posted on our web site at www.gtlic.com and/or sent to you if the changes are material.

EFFECTIVE DATE
This Notice is effective September 23, 2013.

CONTACT INFORMATION
If you have questions regarding this Notice or require further information, you may contact our Customer Service Department at 1-800-338-7452.	Any written complaints should be directed to Guarantee Trust Life Insurance Company, Attention: Privacy Office, 1275 Milwaukee Avenue, Glenview, Illinois 60025.

PN02-1	4	Rev. 9/23/2013 (GTL)