16-1003INSU Questionnaire 2022.pdf

LYFORD CONSOLIDATED INDEPENDENT SCHOOL DISTRICT

QUESTIONNAIRE

1. Do you have an 800 number for questions about claims? _______ yes _______ no

a. If no, do you have a local number or a number we can call collect? _______ yes _______ no

2. Do you assign local representatives to each school district to answer questions? _______ yes _______ no If yes, please name the local representative

Name________________________________________________________________

i. Co. Name____________________________________________________________

Address______________________________________________________________

ii. Telephone No._________________________________________________________

3. Do you have someone who can periodically review problem claims on site? _______ yes _______ no

4. Where are your claims paid from?

5. What is your guaranteed turnaround time for paying claims?

6. Do you require a form to be filled out by each doctor or hospital for the same claim?

i. _______ yes _______ no

7. Do you require a claim form to be filed for each accident? __________

8. Are you registered to do business in Texas? _______yes _________no

9. Is your company rated by Standard & Poor’s? _______yes ________no

a. If yes, what is your rating? ________________

10. Is your company rated by A.M. Best? _____yes _________no

a. If yes, what is your rating? _________________

11. Please list four references of school districts you currently service geographically closest to us.

12. Does your company provide monthly claim reports? _______ yes _______ no

13. Are year-end loss reports furnished? _______ yes _______ no

14. If there are any special features or provisions that have not been shown that your plan has to offer:

15. If you are offering the usual and customary cost benefits, how is it determined here for the Lyford, Texas area? Please state.

STUDENT INSURANCE

QUOTATION FORM

I. QUOTE

REQUESTED

PLAN

BID ALTERNATE PLAN

A. All Athletics under UIL activity, including cheerleaders, band, and school sponsored activities

Total Cost $____________ $____________

B. Catastrophic Coverage Cost per Student $____________ $____________

Total Cost $____________ $____________

C. Total of A & B $____________ $____________

D. Optional Coverage Braces and Appliances $____________ $____________

Vocational and FFA $____________ $____________

Total Cost $____________ $____________

E. Voluntary Plan- Student and School Employees for whole year.

1. 24-hour Coverage $____________ $____________

2. At School Coverage $____________ $____________

F. Other-Option for LCISD

1. Prescription drugs $____________ $____________

2. MRI Extended Coverage $____________ $____________

WE THE UNDERSIGNED SUBMIT THE ABOVE PROPOSAL FOR THE ABOVE MENTIONED ITEM.

I/We have read the proposal requirements, conditions, and specifications which are an integral part of the terms of this contract.

My signature also certifies that the accompanying proposal is not the result of or affected by any unlawful act of collusion with another person or company engaged in the same line of business, or commerce, or any act of fraud punishable under current Texas codes.

Furthermore, I understand that fraud and unlawful collusion are crimes under the Statue Law, and can result in fines, prison sentences, and civil damage awards.

I hereby certify that I am authorized to sign as a Representative for the Firm:

Name of Firm: ______________________________________ Signature: _____________________________________

Address: _____________________________________ Name (Type/Print): _____________________________

_____________________________________________ Title: __________________________________________

Telephone: ___________________________________ E-Mail: _______________________________________

Date__________________________________________

(NOTE: Also submit with this Quotation Form, the Questionnaire and the Coverages and Benefits Section attached).

ATHLETIC/STUDENT INSURANCE

COVERAGES AND BENEFITS

(Part of Quotation Form)

The following are the coverages and benefits for the requested plan and if you choose to offer an alternative plan please fill out the blanks under the column alternative plan.

I. COVERAGES

REQUESTED ALTERNATIVE

PLAN PLAN

1. Maximum Benefits per occurrence $ 25,000.00 $_________________

2. Deductible required None $_________________

3. Maximum number of days between injury and first treatment should be 90 days _______________days

4. Standard benefit period should be at least 260 weeks _______________weeks

5. What is the amount that will be paid as primary None $_________________

6. Catastrophic Coverage:

a. Maximum $5,000,000.00 $_________________

b. Mandatory deductible and excess coverage $ 25,000.00 $_________________

II. BENEFITS – MEDICAL AND DENTAL

Our requested plan bid will be of Usual Customary and Reasonable (UCR) on each, unless otherwise indicated under the Requested Plan column, of the following areas. The space is provided for you to detail any exceptions to this coverage. We do not want bids which use a sharing or percentage of expenses covered; the bid should be for 100% coverage.

QUESTIONNAIRE FORM

REQUESTED ALTERNATIVE

PLAN PLAN

A. Doctors’ Fees:

1. Non-surgical UCR ______________

2. Surgical UCR ______________

3. Anesthesiologist UCR ______________

4. Neurological Consultation UCR ______________

B. Hospital Expenses

1. In-Patient

a. Room and Board UCR ______________

b. Prescribed Medicine UCR ______________

c. Miscellaneous Expenses UCR ______________

2. Out-Patient

a. Emergency Room and Supplies UCR ______________

b. Physiotherapy UCR ______________

c. Non-Surgical fees UCR ______________

d. Other UCR ______________

C. Ambulance Expense

1. One trip per injury Ground Transportation UCR $_____________

2. If necessary trip from one facility to another UCR $_____________

D. X-Rays - Including

1. Interpretation UCR _____________

2. MRI UCR _____________

REQUESTED ALTERNATIVE

PLAN PLAN

E. Dental Fees Per tooth UCR $_____________

Maximum UCR $_____________

F. Injections Vaccines and local anesthetics UCR ______________

G. Braces and Appliances Limit per injury UCR $_____________

H. Motor Vehicle Accident Limit - max per injury UCR $_____________

III. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

A. These benefits are payable for losses which occur within how many days from date of injury 365 days _____________days

B. Loss of Life $ 10,000.00 $_____________

C. Loss of Both Hands, Both Feet, or Sight of Both Eyes $ 20,000.00 $_____________

D. Loss of Hand or one Foot $ 10,000.00 $_____________

E. Loss of sight of one Eye $ 10,000.00 $_____________

IV. OPTIONAL - EXTENDED

Dental Coverage

Usual, Customary and Reasonable to $25,000.00 maximum

Additional Premium for Student $ 8.00 $_____________

(End of Coverages and Benefits Section)