Perkins County Schools 740 Sherman Ave. P.O. Box 829 Grant, NE 69140 308-352-4735 Dear Parents/Guardians: Perkins County School District does not provide any type of health insurance for injuries incurred by your child at school. We encourage all families to have accident coverage on their children, prior to participation in any sports or school sponsored activity. Please read the entire policy offering to determine if this program is a needed supplement to your own primary health insurance. If you feel your coverage is adequate, please sign the bottom this letter and return to your coach, activities director, or the school office. ***Major Expense Benefit- designed primarily for families with no other insurance or with a high deductible; pays up to an additional $15,000 per injury, after benefits under the 24 Hour Plan (or All Sports/Football Plans, if also purchased) have been exhausted (see brochure). The options are: Annual With Premium Expense Benefit A. Full-Time (24 hour)- with No Sports Grds PK-12 Full-Time ($89.00)- with all Sports Grds 7-12 (except football, grds 9-12) B. School-Time- with No Sports Grds PK-12 School-Time-with All Sports Grds 7-12 (except football, grds 9-12) C. Extended Dental Coverage Grds PK-12 $ 89.00 $154.00 $173.00 $238.00
$ 14.00 $ 79.00
$
9.00
D. Football Coverage Grds 9-12 $189.00 (football, grades 7&8 are covered by the All Sports Coverage) In making application for coverage, please read brochures explaining options carefully. 1. 2. 3. 4. 5. Print name, address and other information clearly on the enrollment form. Make check or money order payable to STUDENT ASSURANCE SERVICES, INC Print Student’s name on the face of the check. Detach and retain summary of coverage, and return the enrollment form to school within 10 days. Questions about the plan may be directed to Dale Wamberg, Agent, Student Assurance, Inc., 87724-549 Ave, Wausa, NE 68786-1523, 402-586-2798 or 800-328-2739
Please sign and return the form to school, if you already have adequate insurance for child
Student’s Name______________________________________________School_____________________ We, the undersigned, feel we have adequate insurance protection for our son/daughter while practicing or participating in Interscholastic Sports, or other School Sponsored Activities. Parent’s/Guardian’s Signature_______________________________________________Date:__________