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The Hortonville Area School District provides student accident insurance for all students in pre-school through grade twelve. This insurance is purchased from Student Assurance Services, Inc., and provides the following coverage to students (please refer to the attached Policy Schedule for exact coverage):
a. Attending regular school sessions,
b. Participating in or attending school-sponsored and supervised extracurricular activities,
c. Participating in school-sponsored and supervised interscholastic sports, and
d. Traveling directly to and from school for regular school session; and while traveling to and from school sponsored and supervised extracurricular activities in school-provided transportation.
PLEASE BE ADVISED THAT THE COVERAGE THE SCHOOL DISTRICT IS PURCHASING IS A SUPPLEMENT TO YOUR FAMILY HEALTH INSURANCE. It pays only after your family health or auto policy and then within the limits of the policy’s benefits (explanation of benefits attached). This plan does not cover penalties imposed for failure to use providers preferred or designated by your primary coverage.
CLAIM PROCEDURE
1. Parents notify the school and obtain a claim form immediately. The school will fill out Part A if it’s a school injury.
2. Parents complete Part B. Answer all questions.
3. Parents submit copies of your itemized bills to your own family insurance first, even if you have a large deductible. You will be sent a report called and Explanation of Benefits (EOB).
4. Parents send the claim form, copies of itemized bills and the EOB to:
STUDENT ASSURANCE SERVICES, INC
PO BOX 196
STILLWATER MN 55082
5. The claim will be completed when all of the above documents have been provided. Should you have a question as to the status of a claim, you can contact Student Assurance Services, Inc. at 1-800-328-2739.
NOTE: Students must have been treated by a licensed physician within 60 days of the date of injury. Proof of claim should be submitted within 90 days from the date of the accident, or a reasonable time thereafter not to exceed one year. The company is responsible only for expenses incurred within one year.
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