David Hrvatin Mr. Hrvatin: Please find attached the responsive public records to your request for current insurance policies issued for coverage of the athletic program, its participants, coaches and coaching staff, as well as every payment made in the most recently completed fiscal year for all such insurance policies. We trust that the attached records fulfill your request but, if not, or if you need anything further, please let us know. Thank you Stacey Stacey Brown Public Records Officer University of Toledo
Arch Accident & Health Division Three Parkway, 15th Floor 1601 Cherry Street Philadelphia PA 19102 INTERCOLLEGIATE SPORTS ACCIDENT PROPOSAL FOR University of Toledo Requested Effective Date: August 1, 2012 Underwriting Company: Policyholder State: Arch Insurance Company Ohio Date Proposal Issued: September 4, 2012 THIS PROPOSAL EXPIRES 30 DAYS FROM THE DATE ISSUED Policy Underwritten by Arch Insurance Company 1
REQUESTED POLICY TERM Effective Date August 1, 2012 Requested Policy Period One year from effective date: August 1, 2012 July 31, 2013 Policy Anniversary Date August 1 ACCOUNT PRODUCER: Borden Perlman PROPOSAL BASED ON THE FOLLOWING INFORMATION PROVIDED: 1. RFP 2. CLAIMS HISTORY 3. Number of Eligible Participants: _ 357 TYPE OF PROPOSED POLICY: Blanket Accident which pays for specific losses resulting from Covered Accidents which occur while the insured is participating in a Covered Activity. ESTIMATED ANNUAL PREMIUM: $40,000 Premium is subject to change after receipt of any additional information. CLASSES OF ELIGIBLE PERSONS A person may be insured only under one Class of Eligible Persons even though he or she may be eligible under more than one class. Class 1 Enrolled Full-Time Student Athletes, Enrolled Full-Time Student Managers, Enrolled Full-Time Student Trainers, Coaches, Guest Recruits COVERED ACTIVITIES The following are the Covered Activities for which insurance applies: Sports Coverage The Covered Accident must take place while: 1. participating as a member of the team in a scheduled game, official tournament game, or practice session; or 2. Serving as an equipment manager, scorekeeper, trainer or volunteer worker for the team. The Covered Activity includes travel without delay, deviation or interruption: 2
1. between home and practice sessions for the scheduled game, practice session or competition; or 2. between the site of the game or competition and home or School when the Covered Person is scheduled to attend the game or competition. Benefits are paid as described in this Policy if the Covered Accident occurs while the Covered Person is in a vehicle designated or furnished by the Policyholder, operated by a properly licensed adult driver who is under the direct supervision of the School Travel time includes the time: 1. to or from home or School and the Covered Activity; 2. before the required attendance time; and 3. after dismissal and after completing any extra duties assigned by the School. Supervised and Sponsored Activities The Covered Accident must take place: 1. on the premises of the Policyholder during normal hours of operation or during scheduled functions; or 2. on the premises of the Policyholder during other periods if attending or participating in a Covered Activity; or 3. away from the premises of the Policyholder while attending or participating in a Covered Activity at its scheduled site. The Covered Activity includes travel without delay, deviation or interruption between home and the site of the Covered Activity. Benefits are paid as described in this Policy if the Covered Accident occurs while the Covered Person is in a vehicle designated or furnished by the Policyholder, operated by a properly licensed adult driver who is under the direct supervision of the Policyholder. Travel time includes the time: 1. to or from home and the premises of the Covered Activity; 2. before the appointed time; and 3. after the Covered Activity is completed. COVERED SPORTS All Covered Sports Men Baseball Basketball Cheerleading Cross Country Football Golf All Covered Sports Women Basketball Cheerleading Cross Country Golf Soccer Softball 3
Tennis Swimming and Diving Track and Field Volleyball ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Class 1 Principal Sum: $10,000 Time Period for Loss: 365 days AGGREGATE LIMIT OF LIABILITY Benefit Maximum $500,000 Applies To: All Conditions ACCIDENT MEDICAL And DENTAL EXPENSE BENEFIT Total Benefit Maximum for all Accident Medical and Dental Expense Benefits $90,000 Loss Period First Covered Expenses must be incurred within 90 days after the Covered Accident Benefit Period 24 Months from the Date of the Covered Accident Aggregate Deductible $270,000 Scope of Coverage Full Excess Any Deductibles; Benefit Periods; and Benefit Maximums apply on a per Covered Person, per Covered Accident basis. Covered Expense Benefit Amount: 100% of Usual and Customary Daily Hospital Room and Board (Semi-private room) Daily Intensive Care Unit Ancillary Hospital Expenses Physician Office Visit Physician Surgical Expenses. includes Physicians Assistants Expenses Emergency Room and Supplies Ambulance Outpatient Surgery Visit Outpatient Surgical Room and Supplies Outpatient Laboratory Tests and X-Rays Physical Medicine Anesthesiologist Expenses Dental Expenses Rehabilitative Braces and Appliances, Prescription Drugs Medical Equipment Rental Eyeglasses, Contact Lens and Hearing Aids Expanded Medical Benefit for Sports Heart and Circulatory Condition 4
Pre-Existing Conditions EXCLUSIONS This Policy does not cover any loss or Injury resulting or caused, in whole or part, from: 1. Suicide or attempted suicide; self-destruction; attempted self-destruction while sane or insane. 2. Intentionally self-inflicted injury. 3. War or any act of war; declared or undeclared. 4. Sickness; disease; bodily or mental infirmity; or any bacterial or viral infection; or medical or surgical treatment thereof, except for any bacterial infection that results from: an accidental external cut; or wound; or pyogenic infections that result from accidental ingestion of contaminated food substances. 5. Medical; surgical treatment; diagnostic procedure; administration of anesthesia; or medical mishap; or negligence; including malpractice. 6. Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician. 7. Intoxication or being under the influence of any drug or narcotic. Intoxication is defined by the laws of the jurisdiction where such Accident occurs. 8. Violation of or attempt to violate any duly-enacted law or regulation; or commission or attempt to commit an assault; felony; or other illegal activity. 9. Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy. 10. 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. 11. Travel or activity outside the United States. 12. Participation in any motorized vehicular race or speed contest. 13. Travel in or on any off road and on road motorized vehicle not requiring licensing as a motor vehicle. 14. Aggravation or re-injury of a prior injury that the Covered Person suffered prior to coverage effective date, unless We receive and approve a written medical release from the Covered Person s Physician. 15. Travel in any aircraft Owned; Leased; Controlled; or Chartered by the Policyholder, or any of its subsidiaries or affiliates. 16. Travel or flight in or on any aircraft or including boarding or alighting from: a. while riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or b. while being used for any test or experimental purpose; or c. while piloting; operating; learning to operate; or serving as a member of the crew thereof; or d. while traveling in any such aircraft or device which is owned; chartered; controlled; or leased by or on behalf of the Policyholder of any subsidiary or affiliate of the Policyholder, or by the Covered Person or any member of his household; or e. being flown by the Covered Person or which the Covered Person is a 5
member of the crew; or f. being used for sky diving or hang gliding; pipeline or power line inspection; bungeecord jumping; parasailing; aerial photography or exploration; racing; endurance tests; stunts or acrobatic flying; g. designed for flight above or beyond the earth s atmosphere; h. which is an ultra light; or glider; i. being used for the purpose of skydiving; or parachuting; j. being used by any military authority; except an aircraft used by the Air Mobility Command or its foreign equivalent. In addition to the exclusions above, We will not pay Accident Medical Expense or Additional Accident Benefits for any loss, treatment or services resulting from or contributed to by: 1. Treatment by persons employed or retained by a Policyholder; or by any Immediate Family; or member of the Covered Person's household. 2. Treatment of sickness; disease; or infections except pyogenic infections or viral or bacterial infections that result from the accidental ingestion of contaminated food substances. 3. Treatment of hernia; Osgood-Schlatter's Disease; osteochondritis; appendicitis; osteomyelitis; cardiac disease or conditions; pathological fractures; congenital weakness; hernia; detached retina unless caused by an Injury; or caused by a Covered Accident. 4. Expense incurred for treatment of temporomandibular; or craniomandibular joint dysfunction; and associated myofacial pain (except as provided by the Policy). 5. Covered medical expenses for which the. Covered Person would not be responsible for in the absence of this Policy. 6. Blood, blood plasma; or blood storage; except expenses by a Hospital for processing or administration of blood. 7. Cosmetic surgery; except for reconstructive surgery needed as the result of an Injury. 6
This is a proposal based on the information provided. This is not a contract of insurance. Upon acceptance of the proposal, the terms and conditions of your coverage will be detailed in the policy that is issued. If there are any differences between the terms and conditions of the proposal and the policy issued, the policy will govern. The policy is governed by state laws. Certain terms or provisions may be different if required by the laws of the state. Accepted by: (Signature) Policyholder Name: (Print Policyholder Name) Title: (Policyholder Representative Title) Date Accepted: 7
COVERAGE SUMMARY Policyholder: University of Toledo Requested Effective Date: August 1, 2012 Producer: Borden Perlman Estimated Annual Premium: $40,000 Producer Commission: $0(0%) Date Proposal Released: August 2, 2012 Date Proposal Expires: September 15th, 2012 Accepted by: Print Producer Name: Date Accepted: 8
INVOICE DATE: 8/6/2012 Bill to: University of Toledo For: Univ of Toledo TPA Claims Handling Fee Account Name Policy # Carrier/Code Premium TPA Fee % Amount University of Toledo Agg 99067442 CHUBB 270,000.00 7.00% $18,900.00 Total Amount Due $18,900.00