24-HR-A-DAY
	SCHOOL TIME
	
IMPORTANT PROTECTION FACTS

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	Becomes effective the date premium payment is received by Guarantee Trust Life Insurance Company (GTL), its representa-tivesorschoolofficials(butnotpriortotheopeningdayofschool). Students participating in preschool practice or play for inter-scholastic sports sanctioned by the Ohio High School Athletic Association will be covered as of the date of actual premium pay-ment 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.
	
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	3
	Provides coverage during the hours that school is in regular session.
	
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		Provides 24-hour-a-day protection.

3
	
3
	Provides coverage during the time necessary for travel between the insured’s home and the beginning or end of regular school sessions.

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	Provides coverage while participating in (or attending) activities organized, sponsored and supervised by the school. Coverage is also provided for travel directly to and from such activities in a Designated Vehicle furnished by the school.

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	Coverage expires at the close of the regular school term. (Coverage will be extended while attending academic classes for credit in the summer, when classroom sessions are exclusively sponsored and solely supervised by the school; however, no cov-erage will be provided for travel to and from classes).
	
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		Coverage continues without interruption all summer until school re-opens for the following term.

	
	2018-2019 STUDENT ACCIDENT INSURANCE PLANS

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

n Here areAccident only insurance plans to help cover your child either 24 hours a day (24-Hour Plan) or while in school (School-Time Plan).

expense.
n These plans provide benefits to help meet the cost of medical and Hospital

coinsurance for those plans.
n If you have other insurance, these plans can help offset the deductibles and

n If you have no other insurance, these plans will provide basic coverage.

n 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-A-Day Accident Coverage (Including Summer Vacation)

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Helps protect your child for the entire school year and extends throughout the summer - right up to the day school re-opens. Your child’s coverage is good WORLDWIDE, 24-HOURS-A-DAY. This includes covered accidents:

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At home	At play
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At school	On vacation
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While engaged in sports, except those	Scouting, camping, etc. specifically excluded or for which	During covered travel 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
school sessions for travel time required, but not more than one hour before or
proof of loss and accumulated bills must be received by Guarantee Trust Life
coverage for travel directly to and from your residence to attend regular          To file a claim: Report accidents to the school. Forms will be furnished through the prin-after regular classes. Travel time on the school bus is extended for any addi-          cipal’s office (during vacation time contact the administrators of the plan). Complete
tional time needed.	Insurance Company within 90 days.
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.
In addition, coverage is provided while participating in (or attending) covered	Group BlanketAccident insurance products are issued on Form Series GP-2020 or GP-1200byGuaranteeTrustLifeInsuranceCompany,Glenview,IL.Theseproducts and their features are subject to state availability and may vary by state. Certain exclusions and limitations may apply. The exact provisions governing the insurance are contained in the Policy issued to the Policyholder and certain provisions may be administered to conform to state requirements. The Policy shall control in the event
age please contact the agent administering the program.
Optional Football Only Accident Coverage begins on the date of premium receipt	of any conflict between the Policy and this brochure. For complete details of cover-by GTL, its representatives or school officials, but not prior to the first official date of
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practice; and continues through the date of the last official game of the current
season including playoffs. Football premium covers football only.	300 CoshoctonAve., Mount Vernon, OH 43050 · (800) 278-2544
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K-12-OH-18-19-PDF	Underwritten and1 laimsilwaukeeAve., Glenview, IL 60025 · (800) 622-1993OMPANY (GTL)

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HELP PROTECT YOUR CHILD, HELP PROTECT YOURSELF
Here are your 2018-19 Student Insurance Plans
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‘
Low
What’s Covered? Up to $25,000.00 as described under Coverage and Benefits for:

ACCIDENTS OCCURRING WHILE COVERAGE IS IN FORCE

LOSS FROMACCIDENTALBODILY INJURY RESULTING DIRECTLYAND INDEPENDENTLY OFALLOTHER CAUSES

COVERED MEDICALEXPENSE WHICH BEGINS WITHIN 30 DAYS OF THEACCIDENTAND IS INCURRED WITHIN 52 WEEKS OF THEACCIDENT

Benefits are payable up to the dollar amounts shown

COVERAGE and BENEFITS

BENEFITS PER INJURY
	
Option
	High Option
	
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
	Per Unit
Unit Value determined by the Surgical Schedule
	$80
	$160
	
Anesthesia Services
	Percent of Surgical ScheduleAllowance
	
25%
	
25%
	
Doctor’s Visits Non-Surgical Including Physical Therapy
	
Per visit
	
$25
	
$50
	
	Physical Therapy, per visit
Maximum number of visits per Injury
	$25

3 visits
	$50

3 visits
	
Imaging Procedures
	Including X-Rays & Interpretation
	
$100
	
$200
	
MRI/CAT scan
		$125
	$250
	
Ambulance Expense
		
$100
	
$200

Injury means bodily Injury due to anAccident 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;occursaftertheeffectivedateoftheInsured’scoverageunder the Policy; and occurs while the Policy is in force.All injuries sustained inanyoneAccident,includingallrelatedconditionsandrecurrentsymp-toms of these injuries, are considered a single Injury.

COVERAGE and BENEFITS (continued)

BENEFITS PER INJURY
	Low Option
	High Option
	
Orthopedic Appliances
	
Furnished by the Hospital
	
$100
	
$200
	
Dental Treatment
	Treatment For Injury To Sound, Natural Teeth, per tooth
Up to a maximum of
	
$200 $600
	
$400 $1,200
	
Accidental Death and Dismemberment Only one of these benefits, the largest, will be payable in addition to the benefits shown
	
If Injury causes death or dismemberment within 365 days of theAccident, the plan pays as follows:
Loss of Life
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

EXCLUSIONS - The Policy does not provide benefits for:1) Treatment, services orsupplieswhicharenotMedicallyNecessary;arenotprescribedbya Doctorasnec-essary to treat an Injury; are determined to be 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 received while violating or attempting to vio-late 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 regu-larlyscheduledcommercialairline.6)InjurycoveredbyWorkers'Compensationorthe OccupationalDiseaseLaw.7)Treatmentofillness,diseaseorinfections,exceptinfec-tions which result from an accidental Injury or infections which result from accidental, involuntary or unintentional ingestion of a contaminated substance. 8) Hernia of any type. 9) Injury sustained fighting or brawling, except in self-defense. 10) Suicide or attempted suicide. 11) Loss resulting from the use of any drug or agent classified as narcotic, psycholytic, psychedelic, hallucinogenic, or having a similar classification or effect, unless prescribed by a Doctor. 12) Injury sustained while operating, riding in or upon, mounting or alighting from, any two- or three- or four- wheeled recreational motor/engine driven vehicle or snowmobile or all terrain vehicle (ATV). 13) Injury sus-tained 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 coveragehasbeenpurchased.14)Cosmeticorplasticsurgery,exceptforreconstruc-tive surgery on an injured part of the body. 15) Treatment in any Veteran’s Administration or federal Hospital, except if there is a legal obligation to pay. 16) Loss resulting from being legally intoxicated or under the influence of alcohol as defined by thelawsofthestateinwhichtheInjuryoccurs.17)Dentaltreatment,exceptasspecif-ically stated. 18) Services of an assistant surgeon or Doctor when surgery is per-formed. 19) Eyeglasses, contact lenses, routine eye exams or prescriptions therefore. 20) Prescription Drugs, crutches, braces, artificial limbs, etc., except as specifically stated.

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2018-19 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
	
q$79     q$158 q$91     q$182
	
SCHOOL-TIME PLAN STUDENTS GRADES K-6 STUDENTS GRADES 7-12
	
q$23     q$46 q$37     q$74
	
OPTIONAL FOOTBALL COVERAGE
(GRADES 10-12, INCLUDING GRADE 9 IF PLAYING WITH 10-12)
2018 SEASON ONLY PER PLAYER

q$129 q$258

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

!

PLEASE PRINT CLEARLY
	GUARANTEE TRUST LIFE INSURANCE COMPANY GLENVIEW, IL

STUDENT’S AME
FIRST NAME	MIDDLE INITIAL	LAST NAME
DATE OF BIRTH 		            MALE	FEMALE MONTH                    DAY                YEAR
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.

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