Health Insurance

Mutual of Omaha Insurance Company
Catastrophic Accident Insurance
Description of Coverage for
Eligible Insureds of Members of the Workers' Compensation Self-Insurance Trust

SCHEDULE OF BENEFITS

Covered Accident Deductible*: $25,000.00
*Eligible medical expenses payable under any other insurance policy or service contract will be used to satisfy or reduce the Covered Accident Deductible.

Aggregate Limit of Liability: $5,000,000.00
The maximum amount for which We are liable for an Insured Person for all benefits under this plan due to anyone Accident.

Medical, Dental, Rehabilitative and Custodial Care Expense Benefits:
Benefit Percentage: 100%
Deductible Establishment Period: 24 Month
Maximum Benefit Period: Lifetime
Maximum Benefit Amount: $5,000,000.00
Maximum for Medically Necessary Hospital Inpatient Services and Supplies: Included in Medical Maximum
Maximum for Confinement in an Extended Care Facility Per Calendar Year: $365,000.00

Daily Room And Board Limit For:
Private Or Semi-Pnvate Room: Average Semi-Pnvate Rate Of Hospital In Which Confined
Intensive Care: Reasonable And Customary Charges
Combined Home Health and Custodial Care Maximum Benefit per Calendar Year: $100,000.00

Treatment Of Mental Or Nervous Disorders:
Doctor Fees:
Amount Per Visit: $50.00
Visits Per Day: 1 (One)
Visits Per Calendar Year: 50 (Fifty)
Inpatient Hospital: Up To 45 Days

Chiropractic Benefit Maximum Amount Per Calendar Year: $ 1,000.00

Accidental Death, Dismemberment and Loss of Sight Benefit:
Principal Sum: $10,000.00
Loss Establishment Period: 365 Days

Excess Coverage: Full Excess


Catastrophic Accident Insurance
In spite of our best efforts to prevent them, serious accidents can and do happen every day. If a serious accident occurs, the primary concern should be recovering from the injury ...not the financial loss such an accident can create.

Eligibility
All registered students of a Participating School in Kindergarten through Twelfth grade. Coaches, Managers and or Trainers are also eligible.

Coverage

• Coverage is provided for Injuries incurred during the hours and days when school is in session and while attending or participating in school sponsored and supervised activities on or off school premises.

• Covered travel is team or individual travel for purposes of representing the members of WCSIT, that is to or from the location of a Covered Event and is authorized by the Participating School or Sponsoring Organization, provided the travel is paid for or subject to reimbursement by the Participating School or Sponsoring Organization.

• Coverage is also provided during interscholastic practice and games; intramural games, gym class activities, band practice, cheerleading practice or while at a game, and during any non-sport school sponsored and supervised activity.

• Covered travel is team or individual travel for purposes of representing the members of WCSIT, that is to or from the location of a Covered Event and is authorized by the Participating School or Sponsoring Organization, provided the travel is paid for or subject to reimbursement by the Participating School or Sponsoring Organization.

Effective Date

You will become insured on the later of the policy effective date or the day you meet the eligibility requirements above.

Benefits: Accident Medical Expense

We will pay benefits for Medical Expense incurred by an Insured in excess of the $25,000 Covered Accident Deductible. Benefits will not exceed the Maximum Benefit Limit shown on the Schedule of Benefits. Medical Expense means the Reasonable and Customary charges:

(a) of a professional ambulance service for Medically Necessary transportation to and from a Hospital;

(b) of a Doctor for Medically Necessary care and treatment;

(c) of a Hospital for Medically Necessary inpatient services, including room and board (not exceeding the semi-private room rate for each day of confinement unless a private room is Medically Necessary);

(d) for Medically Necessary inpatient services and supplies, including intensive care services, and daily Hospital charges for personal Hospital services (including television, radio, telephone, barber, and beauty services);

(e) for Medically Necessary out-patient and emergency room care and treatment;

(f) for confinement in an Extended Care Facility;

(g) for Home Health Care;

(h) for medical or surgical services, prescription drugs, and other medical supplies commonly used for therapeutic or diagnostic services, which are Medically Necessary and prescribed by a Doctor operating within the scope of his or her license;

(i) for care and treatment of mental and nervous disorders by a Doctor; and

(j) for treatment of subluxation or dislocation of the spine or treatment for the general purpose of correction of nerve interference and its effects, by manual or mechanical means when interference results from or is related to distortion or misalignment of or in the vertebral column.


Accidental Death, Dismemberment or Loss of Sight
We will pay the benefit amounts shown in the table below, based upon the Principal Sum shown in the Schedule of Benefits for Accidental Death, Dismemberment or Loss of Sight which:

• Results solely from an Injury to an Insured Person which occurs during a Covered Event, and from no other contributory cause; and

• Is sustained within the Loss Establishment Period after the date of Injury.

If an Insured Person sustains more than one such Loss as the result of one Accident, We will pay only one amount, the largest to which he is entitled.

LOSS TABLE . .
Loss and Benefit Amount
Loss of Life: The Principal Sum
Loss of Both Hands: The Principal Sum
Loss of Both Feet: The Principal Sum

Loss of Entire Sight of Both Eyes: The Principal Sum
Loss of One Hand and One Foot: The Principal Sum
Loss of One Hand and Entire Sight of One Eye: The Principal Sum
Loss of One Foot and Entire Sight of One Eye: The Principal Sum

Loss of One Hand: 50% of the Pnncipal Sum
Loss of One Foot: 50% of the Pnncipal Sum
Loss of Entire Sight of One Eye: 50% of the Pnncipal Sum
Loss of Thumb and Index Finger of the Same Hand: 25% of the Principal Sum

Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of a thumb and index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand).

Other Insurance/Excess Nature
Except as provided within the policy, this insurance is excess over any other valid and collectible insurance or similar benefit program available to the Insured Person for a Covered Loss under this policy.

If an Insured Person receives or is entitled to receive benefits or services from any source described within the Other Insurance section of the policy for any benefit category of a Covered Loss for which he or she is entitled under this policy, such benefit will be in excess of the amount of such Other Insurance.

Definitions

"Total Disability" or "Totally Disabled" means for the first 12 months: the inability of the Insured Person, due to a Covered Accident, to engage in substantially the same activities as the Insured Person had engaged in immediately prior to the Covered Accident; and the irrecoverable loss suffered by the Insured Person, due to a Covered Accident, of speech;hearing of both ears; sight in both eyes; use of both arms; use of both legs; use of one arm and one leg; or severely diminished mental capacity due to brain stem or other neurological Injury such that the Insured Person is unable to perform normal daily functions.

For any period thereafter, Total Disability or Totally Disabled means: the inability of the Insured Person, due to a Covered Accident, to engage in any gainful occupation or employment for compensation or profit for which he or she is or may become reasonably fitted by education, training, or experience; and the irrecoverable loss suffered by the Insured Person, due to a Covered Accident, of speech; hearing of both ears; sight in both eyes; use of both arms; use of both legs; use of one arm and one leg; or severely diminished mental capacity due to brain stem or other neurological Injury such that the Insured Person is unable to perform normal daily functions.

"Hospital" means an institution which meets all of the following requirements: (a) It is licensed (if required) as a Hospital by applicable licensing authorities; (b) It is open at all times; (c) It is operated mainly to diagnose and treat illnesses and Injuries on an inpatient basis; (d) It has a staff of one ( 1 ) or more Doctors on call at all times; (e) It has twenty-four (24) hour nursing services by registered nurses; (f) It is not mainly a skilled nursing facility, clinic, nursing home, rest home, convalescence home, or like place; and (g) It has organized facilities for major surgery or provides for such facilities for its patients through formal written agreement with other Hospitals.

"Injury" or "Injuries" means bodily Injury which results directly from an accident and which is independent from disease, sickness or other bodily functions.

"Reasonable and Customary" means an expense that is determined by Us not to exceed the amount usually charged by most providers in the same geographic area for similar treatment, service or purchase, taking into account the nature and severity of the illness or injury. The same geographic area means the same city or town in which the treatment, service or purchase occurs, if the city or town is large enough to obtain a representative charge. In large cities, it may be a section or sections of the city. In smaller urban or rural areas, the geographic area will be expanded as necessary to obtain a representative charge.

Exclusions and Limitations

No benefits are payable for: (a) Illness or disease or medical or surgical treatment thereof, including diagnosis, except: (1) as may be specifically provided for in the policy; (2) as may result from an Injury sustained in a Covered Accident; (3) a cardiovascular accident, stroke or other similar traumatic event caused by exertion while participating in a Covered Event; (b) the aggravation of a condition such as tendonitis, strains, sprains and other similar conditions caused by exertion while participating in a Covered Event; (c) bacterial infection, except infection of and through a wound accidentally sustained; (d) suicide or intentionally self-inflicted Injury while sane; (c) an act of declared or undeclared war, (f) participation in a riot or engagement in or attempt to commit a felony or being engaged in an illegal activity; (g) travel or flight in or descent from any aircraft, unless the Insured Person is a passenger for authonzed group or team travel on a regularly scheduled flight on a commercial airline; or is a passenger on an aircraft chartered solely for the purpose of travel which has a valid airworthiness certificate from the jurisdiction in which operated and which is being operated by a duly licensed pilot; (h) charges which exceed the Reasonable and Customary charges; (i) charges Incurred for dental work unless the Insured Person sustains a Disablement which results in damage to his or her natural teeth; (j) charges Incurred for television, telephone, water pitcher, and other personal convenience items, or expenses for other persons, except as may be specifically provided for elsewhere; (k) charges Incurred for services or supplies not specifically provided for in the policy; (1) charges which would not have been made in the absence of insurance or which the Insured Person is not legally obligated to pay; (m) charges Incurred for cosmetic procedures, unless made necessary by a Disablement; (n) charges Incurred for eye-glasses, contact lenses or hearing aids or for any examination or fitting related to these devices unless made necessary by a Disablement; (o) charges Incurred for care, treatment or service, which is not Medically Necessary to the diagnosis or treatment of a Disablement; (p) charges Incurred for the professional services of a person who either resides with or is an Immediate Family member; (q) charges Incurred for experimental or investigational treatment or procedures; (r) charges Incurred for articles of clothing which are intended for use more than once; (s) treatment of a Disablement sustained as a result or consequence of being Intoxicated, as specifically defined in the policy, or under the influence of any controlled substance unless administered on the advice of a Doctor; (t) the use by the Insured of drugs or narcotics unless used as prescribed by a Doctor for a condition other than drug addiction; (u) routine medical examination and related medical services; (v) charges which are recoverable from any other insurance policy, service contract, Workers' Compensation or other arrangements of insured or self-insured group coverage.

Nonduplication of Benefits

If any item of expense is payable under more than one provision of this policy, payment will be made only under the provision providing the greater benefit.

This description of coverage summarizes the provisions of the SIS20CC policy issued to the Workers Compensaton Self Insurance Trust. Should there be any discrepancy between the policy and this description, policy provisions will prevail.

Underwritten by:
Mutual of Omaha Insurance Company
Special Risk Services
Omaha, NE 68175
800-524-2324