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Dear Parents or Guardians:

South Lewis Central School is providing the opportunity for you to purchase student accident insurance through the Pupil Benefits Plan for the 2019-2020 school year.

The Pupil Benefits Plan, Inc. operates on a non-profit basis and is under the supervision of the New York State Public School Athletic Association. The plan is available to all students in elementary, middle and high schools. The basic philosophy of the plan is to assist parents with expenses. The parent's or guardian's insurance is the primary insurance and the Pupil Benefits Plan is in the excess coverage position. The reimbursement is based on a set schedule - so many dollars for each type of injury. There is no deductible except in the Catastrophe (major medical) portion of the policy.


COVERAGE A:  Covers all school sponsored activities and interscholastic sports including football.  Cost of plan is $77.60 per student.

COVERAGE B: Covers all school sponsored activities and interscholastic sports except football.  Cost of plan is $70.96 per student.

COVERAGE I: Covers all school sponsored activities: excluding all interscholastic sports and intramural tackle football.  Cost of plan is $6.72 per student.

School Sponsored Activities are defined as teacher supervised activities, which are part of the regular program. (This includes playground and field trip activities).

Fund-raising activities by classes or clubs are NOT regarded as a regular school program and are NOT covered.   Fighting and horseplay  are not covered.   Also, illness, self-inflicted  injuries, orthodontia, boils, insect bites, chiropractic treatment, and others that are not accidental bodily injuries are NOT covered.

Pupils are covered for benefits once they get on the school bus on the way to school until they depart the bus on their way home. Pupils who walk to school, drive cars or ride bicycles are NOT covered until they enter the school building.

Benefits  are  available  only  after  all  other  personal  insurance  has  been used.  This is excess coverage only.

It is the patient's responsibility to file a claim with their own insurance company prior to submitting any balance to the Pupil Benefits Plan. Evidence of this must be attached to the claim when submitted to the Pupil Benefits Plan office within one (1) year from the injury date.

A physician's discharge note to return to participation must be submitted with the claim; otherwise the student is left without insurance coverage in the event of a subsequent injury. For example, a student injured in an interscholastic, interschool, or intramural sport will not be covered for an injury in P.E., another intramural or inter-school sport until he has received a discharge date to return to participation by the physician. The student would be covered for all other school-sponsored  activities during this time.

Under this plan, field trips and those activities which are specific to the purpose of the trip ARE covered. For field trips of an unusual distance, including outside the United States and Canada, an itinerary shall be submitted for the Plan's approval at least 30 days in advance of departure date, listing all events and with approval of the Board of Education.

Injuries are to be reported to the Plan's office within 30 days. A minor injury not requiring medical attention does not need to be reported. If a school accident report, made out at the time of the injury and dated, is completed, the plan will accept this evidence in case the 30-day limit is violated.

This form must be completed indicating your intention for obtaining coverage.  If you wish to purchase coverage, money must be sent to school.  Elementary students should return the money to their classroom teacher. High School/Middle School students should submit their money to their coach or to the High School or Middle School Office.(Even if you do not wish to purchase coverage, this form must be completed.) Coverage is offered at the beginning of the school year and at the start of each  sports season. Purchased coverage is effective for the entire school year.


Douglas Premo, Superintendent

2019-2020 South Lewis Student Accident Insurance Coverage - July 01, 2019 to June 30, 2020
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