2013 Youth Football and Cheerleading Insurance Program

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Meryl Crawford
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1 Name of Organization: Your Name (or Individual Responsible for Insurance): Mailing (Organization): City: State: Zip Code: Phone: Fax: (for all correspondence): Do you agree to have your policy/certificates sent via ? Yes No o If No, please mark your preference: Mail Fax Please mark option that applies: New Policy Renewal Adding Teams Do you have a waiver in place and would you be able to provide upon request? Yes No o If No, do you agree to implement the attached sample waiver? (pg.13) Yes No Do you have Risk Management Guidelines/Procedures in place? Yes No o If No, do you agree to implement guidelines provided by our office? Yes No Do you inspect and correct all areas of responsibility or rope off area of concern with signs to prevent use, before play, including the field, benches, bleachers, and all spectator areas? Yes No (if NO, ineligible for program) Do you report any premises concerns to the league, city or field owner after inspection? Yes No Program Coverage Summary 2013 Youth Football and Cheerleading Insurance Program $5,000,000 General Liability Aggregate Limit $1,000,000 General Liability per Occurrence Limit $1,000,000 Personal and Advertising Injury Limit $2,000,000 Products/Completed Operations Aggregate Limit $ 300,000 Coverage for Damage to Rented Premises Limit -Excluded- Spectator Med may be added only if required by contract ($5K) $1,000,000 Non Owned and Hired Auto Limit $2,000,000 Abuse & Molestation Coverage Aggregate Limit $1,000,000 Abuse & Molestation Coverage per Occurrence Limit $1,000,000 Participant Legal Liability $ 100,000 Medical Benefit Option $ 25,000 AD&D Benefit Limit Additional Protection Coverage Summary Increased Liability Limit There are two options to increase the per occurrence limit of your General Liability coverage to $2,000,000 or $5,000,000. Increased Medical Limit Increases the limit on your accident medical coverage to $1,000,000 Fidelity Bond Protects your organization against employee fraud or dishonesty. $25K and $50K options available. Directors and Officers Coverage Broadens your liability protection by providing up to $1,000,000 per occurrence of liability coverage against discrimination, acts beyond granted authority, and failure to deliver services. Sports Equipment Coverage Sport equipment coverage insures against loss or damage of sports equipment, snack bar equipment, uniforms, and playing equipment. 1

2 Program Rates There are three accident medical deductible options available; all teams must be in the same deductible category. Each tackle or flag team you purchase includes one cheer squad; additional cheer squads may be purchased. For Example: (1 Football Team = 1 Cheer Squad Included) (Rates below include General Liability & Accident Medical) Age Group Number of Teams $0 Deductible $100 Deductible $250 Deductible 9 and Under X $204 $187 $177 = Premium Due 12 and Under X $289 $251 $234 = 15 and Under X $400 $371 $362 = Flag all ages X $95 $87 $83 = Additional Cheer Squads (in addition to squads included ) X $118 $112 $107 = Premium Due: $ **Note: Minimum Premium is $300** Additional / Optional Protection Rates (Total # of teams must match Total # of teams above) Increased Liability Limit (Excess) (Up to $2,000,000 per Occurrence) Total # of Teams Rate (per team) Premium Due X $17 = (Up to $5,000,000 per Occurrence) OR X $68 = Increased Medical Limit (Cat Med) (Up to $1,000,000) Total # of Teams Rate (per team) Premium Due Football X $37.50 = (Must equal number of teams as above) Additional Cheerleading Squads X $50.00 = (Must equal additional squads as above) 2

3 Additional Protection Rates (Continued) Fidelity Bond See back of application for additional form(s) to be completed $25,000 of Coverage per Chapter/Association Premium Due Rate $170 X = OR $50,000 of Coverage per Chapter/Association Premium Due Rate $284 X = (Max 5 Positions to be covered) Directors & Officers See back of application for additional form(s) to be completed $1,000,000 of Coverage per Chapter/Association Rate $260 X (# of boards) = $ Premium Due Sports Equipment Coverage - See back of application for additional form(s) to be completed Please mark here if you would like the minimum amount of coverage ($17,000 worth of equipment = $255 minimum premium) If No, please specify amount of coverage below Please round figures to nearest dollar amount Coverage amount (Rate is $1.50 per $100 in coverage) X $0.015 = Premium Due (Minimum Premium: $255) Please attach a detailed list itemizing any covered items valued over $1,000 3

4 Policy Effective Date Requested: / / Policy will begin upon receipt of application and premium, and will be valid for an annual term. No backdating will be allowed under any circumstances. To add teams at any time during the policy year please complete another application and send to our office along with premium. Teams cannot be deleted or removed after policy has been enforced and no refunds will be given. ALL PREMIUMS ARE FULLY EARNED AT POLICY INCEPTION Total Amount From Premium Due Columns: $ Application Fee: $ 20 ($20 fee applies to New and Renewal policies. If adding teams or coverage to current policy, you may waive $20 fee.) Total Amount Due For Premiums and Fees: $ Expedite Fee: $ 100 (Optional If Proof of Insurance Needed Within 1 Business Day) Total Amount Including Expedite Fee: $ I confirm that all information provided on this application is true to the best of my knowledge and understand that any inaccurate or misleading statements may affect any claims made against the associated policy. I verify I have read and understand all information contained in this application and that Gagliardi Insurance Services reserves the right to deny all or part of any coverage offered. I understand that this application only provides a summary of coverage and that full details of the coverage or a copy of the insurance policies offered or purchased can be provided upon request. Insurance requirements may vary by venue and state. I understand that I am responsible for ensuring that I have purchased adequate coverage based on the location of the event or other covered activities. Date: Applicant Signature: Print Name and Title: ** Please sign and submit this application via mail, fax or along with your method of payment (check by mail / check or credit card by fax/ forms attached) ** Gagliardi Insurance Services, Inc Lincoln Avenue Suite 202 San Jose, CA Phone: (800) Fax: (408) sales@gsportsinsurance.com 4

5 Fidelity Bond Application For multiple associations, make as many copies as required. This application is for a Fidelity Bond, which covers employee fraud or dishonesty. By completing this portion of the application you will receive a Fidelity Bond. Check One: Amount of Bond: $25,000 of Coverage per Chapter/Association per Loss Deductible: $250 per claim Premium: $170 Amount of Bond: $50,000 of coverage per Chapter/Association per Loss Deductible: $250 per claim Premium: $284 EFFECTIVE DATE OF POLICY / / - / / Conference Name: President: Association Name: : City: State: Zip Code: Have you sustained any employee dishonesty losses in the last six years? Yes No 5 POSITIONS TO BE COVERED: FULL NAME OF PERSON: (Job Title) This bond covers only those 5 persons holding the positions designated while such person is engaged in activities sanctioned by the League. We must be notified in writing of any changes in Board of Directors. Date: Signature: 5

6 Sports Equipment Application For multiple associations, make as many copies as required. This application is for Sports Equipment Coverage. Buildings and food products are NOT covered under this policy. EFFECTIVE DATE OF POLICY / / - / / Conference Name: President: Association Name: : City: State: Zip Code: Deductible $500 Rate: $1.50 per every $100 of coverage subject to a $255 minimum premium. *If you chose $255 minimum premium, you receive $17,000 worth of equipment coverage. Amount to be insured: Premium $ Total Premium (.015x amount of equipment-or-$255, whichever is greater). Please round figures to closest dollar amount. List all items valued over $1,000 with Serial Numbers (if equipment has serial number). Attached additional sheet if necessary Equipment Serial Number Equipment Serial Number Complete address where equipment is stored: 1.) Is equipment stored in a locked facility with either a deadbolt or external locking device? YES NO 2.) Is there Burglar Alarms Fire Alarms Automatic Sprinklers None (check all that apply) Coverage is void if stored at a residence or in a vehicle Date: Signature: 6

7 Directors & Officers Application For multiple associations, make as many copies as required. Conference Name: Association Name: : City: State: Zip Code: EFFECTIVE DATE OF POLICY / / - / / 1.) Have any loss payments been made under any prior or current D&O or similar insurance? YES NO 2.) Has any league person given written notice under the provisions of any prior D&O liability or similar insurance of circumstances which might give cause for a claim against any insured person(s)? YES NO 3.) Are you aware of any circumstance which would afford valid grounds for any future claim(s) which would fall within the scope of this coverage? YES NO DECLARATION AND SIGNATURE: (Signature of Association President is Mandatory) Although the signing of this application shall be the basis of the contract should a policy be issued, the company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. Date: Signature: The cost of this policy is $ Deductible $1,000 7

8 Additional Insured/ List *Complete MUST be included for completion of certificate. Attach additional list of certificate holders when necessary. 8

9 Credit Card Authorization Form (Visa/MasterCard/Discover only) Name (as it appears on the card): Billing : Billing City, State and Zip Code: Credit Card Number: Visa/Mastercard/Discover only. Expiration Date: V Code: 3 Digit code on back of the credit card Amount to Be Billed: Will be obtained by phone Will be obtained by phone Will be obtained by phone Telephone Number : (Our office will contact you for V-Code / Expiration Date) Name of Organization : (Must match name of organization on page 1 of application) I,, authorize the use of my credit card described above for charges related to the services and products provided by Gagliardi Insurance Services, Inc. Cardholder s Signature Date 9

10 E-Check Payment Option Please fill out section below and attach a voided check in the space provided. Do NOT mail in check. I, authorize Gagliardi Insurance Services, Inc. to charge my account in the amount of $ for insurance premium. My account information is as follows: Bank Name: Bank Account Type: _(Checking, Savings, Business Check) Bank ABA Routing Number: Bank Account Number: This payment authorization is valid and to remain in effect unless I,, notify Gagliardi Insurance Services, Inc. of its cancellation by sending written notice either by , fax, or mail. Signature Date Printed Name Attach Check Here 10

11 *** This form shows you understand you are buying into a Master Policy rather than an Individual Policy. Simply sign and date the form, include with final submission. G.A.R.D. TRUST NATIONAL YOUTH FOOTBALL MEDICAL PARTICIPATION AGREEMENT The undersigned hereby requests to become a Participant in the G.A.R.D. Trust, established under a Trust Agreement entered into in the State of Rhode Island on the 1 st day of October, 1987 as amended, by BankNewport as Successor Trustee to Citizens Bank of Rhode Island. As a Participant, the undersigned shall be bound by the terms of the Trust Agreement and hereby appoints the Administrator to represent the Participant in all dealings with the Trustee having to do with the Insurance Fund. If accepted as a Participant herein, the undersigned may, upon 30 days written notice, subject to the Trust Agreement, withdraw from the Trust, and terminate its participation therein. By any such withdrawal, a Participant shall relinquish all claims to any portion of the Insurance Fund on the date of withdrawal. In the event of any change to the insurance affecting this Participant, the Administrator shall provide the same notification to the Participant as provided the Trustee under the Master Policy identified below. The Participant agrees to notify all of its members once it is notified of any change to the insurance. Name (printed): Signature: Date: For information purposes only: Benefits for eligible persons of the Participant are provided under Master Policy ACCEPTED by the Trust Administrator: James R. Hamilton By: Administrator 11

12 *** If you purchased Increased Medical / Cat Med, please also sign and date and return to our office. G.A.R.D. TRUST NATIONAL YOUTH FOOTBALL CAT MEDICAL PARTICIPATION AGREEMENT The undersigned hereby requests to become a Participant in the G.A.R.D. Trust, established under a Trust Agreement entered into in the State of Rhode Island on the 1 st day of October, 1987 as amended, by BankNewport as Successor Trustee to Citizens Bank of Rhode Island. As a Participant, the undersigned shall be bound by the terms of the Trust Agreement and hereby appoints the Administrator to represent the Participant in all dealings with the Trustee having to do with the Insurance Fund. If accepted as a Participant herein, the undersigned may, upon 30 days written notice, subject to the Trust Agreement, withdraw from the Trust, and terminate its participation therein. By any such withdrawal, a Participant shall relinquish all claims to any portion of the Insurance Fund on the date of withdrawal. In the event of any change to the insurance affecting this Participant, the Administrator shall provide the same notification to the Participant as provided the Trustee under the Master Policy identified below. The Participant agrees to notify all of its members once it is notified of any change to the insurance. Name (printed): Signature: Date: For information purposes only: Benefits for eligible persons of the Participant are provided under Master Policy ACCEPTED by the Trust Administrator: James R. Hamilton By: Administrator 12

13 Waiver of Liability, Release For and in consideration of the undersigned participant's registration with (Name of Organization) ("Organization") and being allowed to participate in events and member activities, participant and the parent(s) or legal guardian(s) of participant waive, release and relinquish any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to participant or participant s parent(s) or legal guardian(s) arising out of participation in events, or sports, and/or activities incidental thereto, whenever or however they occur and for such period said activities may continue, and by this agreement any such claims, rights, and causes of action that participant and/or participant's parent(s) or legal guardian(s) may have are hereby waived, released and relinquished, and participant and participant s parent(s)/guardian(s) do so on behalf of their heirs, executors, administrators and assigns. Participant and participant's parent(s)/guardian(s) acknowledge, understand and assume all risks relating to events or sports participation and activities incidental thereto, and understand that activities incidental thereto involve risks to participant's and participant's parent('s)/guardian('s) person including bodily injury, partial or total disability, paralysis and death, and damages which may arise there from and that we have full knowledge of said risks. These risks and dangers may be caused by the negligence of the participant, participant's parent(s)/guardian(s)or the negligence of others, including the organization, its affiliates, members, event hosts, other participants, other parents and legal guardians, coaches, officials, sponsors, advertisers, owners and operators of the premises used to conduct any event and each of them, their officers, directors, agents and employees (collectively, "releasees"), and include risks arising from the conditions and use of facilities and related premises. I/We further acknowledge that there may be risks and dangers not known to us or not reasonably foreseeable at this time. Participant and participant's parent(s)/guardian(s) acknowledge, understand and assume the risks, if any, arising from the conditions and use of facilities and related premises, whether as a participant or a spectator, including without limitation, the risks involved with participating in the Organization s activities. Participant and participant's parent(s)/guardian(s) further acknowledge and understand that included within the scope of this waiver and release is any cause of action (including any cause of action based on negligence) arising from the performance, or failure to perform, maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said facilities, for negligent selection of certain releasees, or negligent supervision or instruction by releasees. Participant and participant's parent(s)/guardian(s) acknowledge, understand The Organization reserves the right to photograph facilities, activities and program participants for potential future use. All photos remain the property of the Organization and may be used for publicity and promotional services. Consent to Medical Treatment of Minor: I hereby give my consent to have the above applicant treated by a physician or surgeon in case of sudden illness or injury while participating in the above event. It is understood that the Organization provides no medical insurance for such treatment under its liability insurance coverage. Medical benefits for such treatments/injuries may be provided with proof of medical coverage purchased through the Organization. The location of the activity or the nature of the illness or injury may require the use of emergency medical personnel. Participant and participant's parent(s)/guardian(s) agree if any claim for personal injury or wrongful death is commenced against releasees, he/she shall defend, indemnify and save harmless from any and all claims or causes of action by whomever or wherever made or presented for his/her personal injuries, property damage or wrongful death. Participant and participant's parent(s)/guardian(s) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential dangers and risks and understand these waivers and releases are necessary to allow the activities of the Organization to exist in its present form. Participant Signature Age Date Signed Participant Name (Print) Parent or Guardian Signature (if under 18) Date Signed 13

Program Coverage Summary

Program Coverage Summary Amateur Sports Team & League Liability Insurance Application -No participant coverage- Name of Organization: C/O (Individual Responsible for Insurance): Mailing : City: State: Zip: Phone: ( ) Fax: ( )