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Claim Procedure In the event of Injury or Sickness, students should: 1) Report at once to the Student Health Service or Infirmary for treatment, or when not in school, to the nearest Physician or Hospital. 2) Secure a Company claim form from the Student Health Service or from the address below, fill out the form completely, attach all medical and hospital bills and mail to the address below. 3) File claim within 30 days of Injury or first treatment for a Sickness. Bills must be received by the Company within 90 days of service. Bills submitted after one year will not be considered for payment except in the absence of legal capacity. The Plan is Underwritten by: UnitedHealthcare Insurance Company Submit all Claims or Inquiries to: UnitedHealthcare StudentResources P.O. Box 809025 Dallas, Texas 75380-9025 1-888-455-9402 Sales/Marketing Service: UnitedHealthcare StudentResources 805 Executive Center Drive West, Suite 220 St. Petersburg, FL 33702 Please keep this Certificate as a general summary of the insurance. The Master Policy on file at the school contains all of the provisions, limitations, exclusions and qualifications of your insurance benefits, some of which may not be included in this Certificate. The Master Policy is the contract and will govern and control payment of benefits. This Certificate is based on Policy 2012-1806-1 v2
[ suffield academy [ Suffield, Connecticut / 860.386.4400 2012/13 student forms ID# date of birth PRIVATE MUSIC LESSON PROGRAM The Music Department of Suffield Academy offers private lessons at all levels for voice as well as instruments. Lessons are offered once each week and students are expected to practice regularly. A year-round commitment is important for substantial growth. In order to secure contracts with professional teachers, it is necessary for the Academy to commit financially to them in advance of the start of lessons. The cost of a full year of lessons is $925 (24 lessons), payable in advance to Suffield Academy. Students interested in scheduling private lessons should read the list of Student/Teacher Commitments below and fill in and sign the statement at the bottom, returning it with a check by September 10. STUDENT/TEACHER COMMITMENTS 1. In the case of an unexcused absence from a lesson, the teacher will be paid and the lesson will not be rescheduled. In the case of two unexcused absences, the student’s parents and advisor will be notified and the possibility of discontinuing lessons discussed. If the number of these absences continues to four, parents and advisor will be notified again with the assumption that the student is not interested in lessons. The teacher will be paid for the lessons missed, and any balance of payment returned. 2. In the case of an excused absence (i.e., sudden illness or emergency), the lesson will be rescheduled by the teacher if documentation is presented (a note provided by the school nurse or doctor). If the student is not able to come to school on the day of a lesson (due to illness), in addition to notifying the school, the teacher and the Music Department office must be notified directly and immediately. It is the responsibility of the student to reschedule the lesson with the teacher. If proper notification does not take place, the lesson will not be rescheduled. 3. If a student cannot make a lesson for some other personal or school-related reason, and notifies the teacher at least 24 hours in advance, every effort will be made to reschedule the lesson. If the teacher cannot be reached directly, the Music Department must be notified at least 24 hours in advance. Please arrange for private music lessons at Suffield Academy for: Student Name Instrument Please send payment for $925.00 (payable in U.S. dollars to Suffield Academy) along with a copy of this form to Suffield Academy, Attn: Tom Gotwals 185 North Main Street, Suffield, CT 06078. I understand and agree with the policies regarding private lessons. Parent or Guardian Name (please print and sign here if you intend to use a printed copy of this form) Date By checking this box and entering the student ID number above, you are signing this document electronically. [ FORM: MUSIC / DUE: 07.15.12 [
Page 1 and 2: Suffield Academy Registration Packe
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Page 19 and 20: 2012-2013 STUDENT INJURY AND SICKNE
Page 21 and 22: THIS LIMITED HEALTH BENEFITS PLAN D
Page 23 and 24: Schedule of Medical Expense Benefit
Page 25 and 26: OTHER Ambulance Services, when medi
Page 27 and 28: 4. Drugs available over-the-counter
Page 29 and 30: Home health care shall consist of,
Page 31 and 32: Benefits for Postpartum Care If an
Page 33 and 34: Benefits for Pain Management Benefi
Page 35 and 36: 13. Immunizations, except as specif
Page 37: Scholastic Emergency Services: Glob
Page 43 and 44: Since 1921 Since 1921 6078 • (860
Page 45 and 46: 06078 • (860) 668-7315 • Fax (8
Page 47 and 48: Dear Sufüeld Academy Parents and S
Page 49: [ [ suffield academy [ Suffield, Co

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