Northern Lebanon School District Student iPad/Laptop Insurance

2016-2017 School Year The electronic devices provided to the students in the Northern Lebanon School District are costly pieces of equipment that require students to follow usage guidelines and to use caution in handling the equipment. Insurance is highly recommended, but is not mandatory. If you choose not to purchase insurance and the device is damaged, the parent/guardian is financially responsible for all repair or replacement costs. The non-refundable insurance fee must be paid annually.

PARENTS/STUDENTS MAY BE RESPONSIBLE FOR THE DEDUCTIBLE FOR EACH REPAIR CLAIM SUBMITTED. THE AMOUNT OF THE

DEDUCTIBLE WILL BE $60 FOR THE FIRST CLAIM AND INCREASE BY $20 PER CLAIM PER YEAR. IF NO CLAIMS ARE SUBMITTED, THE

DEDUCTIBLE WILL DECREASE BY $10 EACH YEAR.

The insurance fee scale for the 2016-2017 school year is listed below. If you qualify for free or reduced lunch status, you also

qualify for adjusted insurance costs, as long as your paperwork has been completed and submitted by September 2, 2016. Please make checks or money orders payable to Northern Lebanon School District. No cash will be accepted.

The school district encourages the purchasing of insurance, as it provides peace of mind for the student and parent. In addition to providing coverage for accidental damage, the insurance fee includes the following benefits: The insurance policy covers accidental damage. The only exclusions are dishonest, fraudulent, intentional, negligent or criminal acts, which would result in the complete repair and/or replacement to be paid by the student.

Any damage caused deliberately will be classified as vandalism. Students will be billed for repairs caused by vandalism, and disciplinary action, including expulsion. If the laptop is misplaced, lost, or stolen, you must notify the school immediately and file a police report. The insurance policy does not cover loss or theft that occurs off of school property; you are responsible for replacement costs. Parents and guardians may substitute homeowners or other personal insurance for District-procured laptop insurance. You may contact your homeowner’s or renter’s insurance to purchase additional coverage.

PLEASE COMPLETE THE INFORMATION ON THE BACK OF THIS FORM AND RETURN TO THE SCHOOL OFFICE.

Family Plan (more than 1 child

receiving iPad/Laptop)

Single Student not Eligible for Free or

Reduced Lunch Status

Single Student eligible for Reduced

Lunch Status

Reduced Lunch Family Plan

(more than 1 child receiving iPad/Laptop)

Eligible for Free Lunch Status

$50 $35 $15 $35 $0

iPad Laptop Device

Reduced deductible for each year of participation (until new device is issued). Deductible decreases by $10 every year of participation if no incidents occur.

Keep the device! If you participate in the plan all four years, you may keep the device at the end of the four years.

Stylus for the iPad Wireless mouse for the laptop

Personal set of earbuds with mic for the iPad USB thumb drive for the laptop

If you have more than one student attending Northern Lebanon, the fee for your family is $50.00 (Reduced Lunch Family Plan is $35.00) and must be paid by September 2, 2016.

Please fill out a form below and return to the OLDEST student’s school office.

Please select an insurance option:

_____ I DO wish to purchase insurance. I have read and understand this document and agree to the conditions described for student use of iPads or laptop computers.

Please complete the following information:

Oldest Student Printed Name: _____________________________ Student Number: _______________________

Student Signature: ________________________________________ Student Grade Level: ____________________

School Attends (Circle one): EH FB LD JT MS HS

FAMILY PLAN (Please complete below):

Sibling Printed Name: ________________________________ Student Number: ____________________ School: ____________ Grade _____

Sibling Printed Name: ________________________________ Student Number: ____________________ School: ___________ Grade_____

Sibling Printed Name: ________________________________ Student Number: ____________________ School: ____________ Grade _____

Student(s) is/are eligible for: ___________Free Lunch __________ Reduced Lunch

Parent/Guardian Signature: ___________________________ Printed Name _________________________________ Date: _____________

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_____ I DO NOT wish to purchase insurance at this time. I understand that by doing so, I am financially responsible for all repair costs should the computer become damaged. I have read and understand this document and agree to the conditions described for student use of iPads or laptop computers.

Please complete the following information:

Oldest Student Printed Name: ____________________________ Student Number: _________________________

Student Signature: ________________________________________ Student Grade Level: ______________________

School Attends (Circle one): EH FB LD JT MS HS Sibling Printed Name: ________________________________ Student Number: ____________________ School: ____________ Grade _____

Sibling Printed Name: ________________________________ Student Number: ____________________ School: ___________ Grade_____

Sibling Printed Name: ________________________________ Student Number: ____________________ School: ____________ Grade _____

Parent/Guardian Signature: ___________________________ Printed Name _________________________________ Date: _____________

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For Office Use Only: PAYMENT AMOUNT __________ CHECK NUMBER: _________ VERIFIED FREE/REDUCED ______________