Tackle Football Flag Football Cheerleaders. Youth Sports Accident Medical Insurance for Tackle Football Teams, Flag Football Teams, and Cheerleaders

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Kelly Hood
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1 Tackle Football Flag Football Cheerleaders Youth Sports Accident Medical Insurance

2 The Accident Coverage Who Is Covered All players, cheerleaders, coaches, managers, and volunteers of the team(s) specified in the application. Covered Activity Participation in scheduled and supervised games, practice sessions, and group travel as a member of an insured team. Medical Expense Benefit If the Covered Person incurs eligible expenses as the direct result of a covered injury and independent of all other causes, the Company will pay the charges incurred for such expense within 365 days, beginning on the date of accident. Payment will be made for eligible expenses in excess of the applicable Deductible Amount, not to exceed the Maximum Medical Benefit. The first such expense must be incurred within 90 days after the date of the accident. Eligible expense means charges for the following necessary treatment and service, not to exceed the usual and customary charges in the area where provided. Medical and surgical care by a physician Radiology (X-rays) Prescription drugs and medicines Dental treatment of sound natural teeth Hospital care and service in semiprivate accommodations, or as an outpatient Ambulance service from the scene of the accident to the nearest hospital Orthopedic appliances necessary to promote healing Excess coverage: This plan does not cover treatment or service for which benefits are payable or service is available under any other insurance or medical service plan available to the Covered Person. Accidental Death and Dismemberment Benefit If a covered injury results in any of the losses specified below within 365 days after the date of the accident, the Company will pay the applicable amount: Full Principal Sum for loss of life Full Principal Sum for double dismemberment Full Principal Sum for loss of sight of both eyes 50% of the Principal Sum for loss of one hand, one foot, or sight of one eye 25% of the Principal Sum for loss of index finger and thumb of same hand. We will not pay more than the Principal Sum for this Benefit for all losses due to the same accident. Exclusions and Limitations This plan does not cover any loss to or resulting from: Suicide, self-destruction, attempted self-destruction or intentional selfinflicted injury while sane or insane. War or any act of war, declared or undeclared. Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances. Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician. Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy. Injuries paid under Workers Compensation, Employer s liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder. Injury caused by, contributed to or resulting from the Covered Person s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person s Physician. Service or Active Duty in the armed forces, National Guard, military, naval or air service or organized reserve corps of any country or international organization. Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an Immediate Family member of the Covered Person. Treatment of a hernia, Osgood- Schlatter s disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, whether or not caused by a Covered Accident. Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy. Eyeglasses, contact lenses, hearing aids. Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from: While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers. Tackle Football League Discounts Players 5% Discount Players 6% Discount Players 7% Discount Players 8% Discount 611 Players Or More 8% Discount Note: The league discount applies to tackle football participants only.

3 Youth Sports Accident Medical Insurance Cheer Cheerleaders Flag Flag Football Tackle Tackle Football Accidental Death Benefit: $2,500 Maximum Medical Benefit: $5,000 9 and Under $3.66 $5.70 $ and Under $2.53 $4.20 $ $3.66 $5.70 $ $2.53 $4.20 $ $4.06 $6.30 $ $2.80 $4.70 $ $6.66 $10.20 $ $4.73 $7.70 $ and Under $3.13 $5.20 $ and Under $1.93 $3.60 $ $3.13 $5.20 $ $1.93 $3.60 $ $3.53 $5.80 $ $2.50 $4.00 $ $5.79 $9.60 $ $4.35 $6.90 $ and Under $2.80 $4.70 $ and Under $1.20 $2.90 $ $2.80 $4.70 $ $1.20 $2.90 $ $3.13 $5.20 $ $2.15 $3.30 $ $5.13 $8.60 $ $4.05 $6.00 $76.30 Accidental Death Benefit: $10,000 Maximum Medical Benefit: $10,000 9 and Under $4.80 $8.50 $ and Under $3.87 $6.60 $ $4.80 $8.50 $ $3.87 $6.60 $ $5.47 $9.60 $ $4.46 $7.40 $ $9.00 $15.40 $ $7.27 $12.20 $ and Under $4.40 $7.50 $ and Under $3.25 $6.00 $ $4.40 $7.50 $ $3.25 $6.00 $ $5.00 $8.40 $ $4.05 $6.80 $ $8.20 $13.70 $ $6.87 $11.60 $ and Under $4.07 $6.80 $ and Under $2.95 $5.70 $ $4.07 $6.80 $ $2.95 $5.70 $ $4.67 $7.80 $ $3.80 $6.20 $ $7.53 $12.70 $ $6.55 $11.00 $83.80 Age Classification if more than 10% of the players on a team exceed the maximum age in the age classification, then the next higher classification must be used. Minimum Policy Premium is $ Premium is Fully Earned Upon Policy Inception

4 Youth Sports Accident Medical Insurance Cheer Cheerleaders Flag Flag Football Tackle Tackle Football Accidental Death Benefit: $10,000 Maximum Medical Benefit: $15,000 9 and Under $5.13 $9.00 $ and Under $4.26 $7.20 $ $5.13 $9.00 $ $4.26 $7.20 $ $5.73 $10.10 $ $4.80 $8.20 $ $9.47 $16.40 $ $7.93 $13.30 $ and Under $4.80 $8.00 $ and Under $3.82 $6.80 $ $4.80 $8.00 $ $3.82 $6.80 $ $5.33 $8.90 $ $4.50 $7.90 $ $8.70 $14.70 $ $7.55 $12.85 $ and Under $4.53 $7.50 $ and Under $3.51 $6.50 $ $4.53 $7.50 $ $3.51 $6.50 $ $5.06 $8.40 $ $4.10 $7.50 $ $8.26 $13.90 $ $7.20 $12.50 $86.50 Accidental Death Benefit: $10,000 Maximum Medical Benefit: $25,000 9 and Under $5.60 $10.00 $ and Under $4.66 $8.00 $ $5.60 $10.00 $ $4.66 $8.00 $ $6.33 $11.20 $ $5.33 $9.00 $ $10.39 $18.00 $ $8.73 $14.60 $ and Under $5.27 $8.80 $ and Under $4.00 $6.80 $ $5.27 $8.80 $ $4.00 $6.80 $ $5.87 $9.80 $ $4.53 $7.70 $ $9.66 $16.10 $ $7.39 $12.40 $ and Under $4.93 $8.40 $ and Under $3.64 $5.90 $ $4.93 $8.40 $ $3.64 $5.90 $ $5.60 $9.30 $ $4.20 $6.70 $ $9.06 $15.30 $ $7.05 $11.40 $92.50 Age Classification if more than 10% of the players on a team exceed the maximum age in the age classification, then the next higher classification must be used. Minimum Policy Premium is $ Premium is Fully Earned Upon Policy Inception.

5 Youth Sports Accident Medical Insurance Part I Proposed Policyholder Please print or type a. Full Legal Name of Proposed Policyholder b. Mailing Address c. Contact Person Street City State Zip Phone Number Address d. Requested Effective Date* (Annual coverage is provided) *Policy will become effective on the Requested Effective Date if (a) all required information is provided and (b) the Company has received the initial premium on or before that date. Part II Premium Rates And Benefits (minimum premiums are fully earned) Plan of Benefits Accidental Death & Dismemberment Principle Sum $ Maximum Medical Expense Benefit $ Deductible Amount $ Cheerleaders Flag Football Tackle Football Age Group Rate Per Player ($) Number Eligible Total Rate ($) rate x number Total Premium = $ Discounts (if applicable) = $ Total Policy Premium = $ Minimum Premium is $ Part III Payment Premium is Fully Earned Upon Policy Inception. (If you purchase both accident and liability coverage, you only need to complete payment information once) Choose one of the following options. Please initial your choice: Enclosed is my check for the total premium. Please change my: Visa MasterCard Discover American Express For Premiums less than $1,000.00, a $10.00 convenience fee will be added. For Premiums $1, and higher, a convenience fee equal to 2.5% of the premium will be added. Name on Card Cardholder Billing Address Card # Exp. Date (mm/yyyy) Security Code Part IV Acknowledgements and Signatures a. This summary of coverage and exclusions is no substitute for reading the entire policy. To receive an entire policy, contact the program administrator. b. Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material there to, commits a fraudulent insurance act, which may be a crime. c. Applicant s Acknowledgement I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this application are true and complete. I understand and agree that (a) this application will form part of any policy issued, (b) no information given to or acquired by any representative of the Company will bind it, unless it is in writing on this application, (c) no waiver or modification will bind the Company unless it is in writing and is signed by an executive officer of the Company, and (d) only those persons eligible under the terms of an issued policy will be insured. Signed for the Proposed Policyholder Signed by Licensed Agent Agency Name and License Number Date Agent Phone Number Agent Address Agency Mailing Address Francis L. Dean & Associates, Inc S. Naperville Rd., Bldg-B P.O. Box 4200, Wheaton, IL (800) FAX (630) United States Fire Insurance Company, A rated by A.M. Best Company. A member of the Crum & Forster group of companies. Form: TF BAH /2014

Baseball Softball T-ball. Baseball/Softball/T-ball Accident Insurance

Baseball Softball T-ball. Baseball/Softball/T-ball Accident Insurance Baseball Softball T-ball Baseball/Softball/T-ball Accident Insurance Baseball/Softball/T-ball Accident Insurance Who is Covered All players, coaches, managers, and volunteers of the teams specified in