Accident – Medical Insurance 11.0. Who is covered? All registered United States Youth Soccer Association members, including their employees, officials, team members age 19 and under, coaches and referees whose applications and premiums have been accepted are covered. 11.1. When are they covered? While participating in the sanctioned play or practice of soccer under the direction and supervision of an authorized official; while traveling as an organized group at the direction of an authorized official directly and uninterruptedly to or from such play or practice; and while participating in other scheduled group activities which are directly supervised by an authorized official. Benefits: Accident Medical Expense Benefit: $100,000 Maximum * Accidental Death Benefit: $10,000 Principal Sum Accidental Dismemberment Benefit: $10,000 Maximum Dental Benefit: $1,000,000 Maximum * Deductible: $1,000 per claim * *Excess Provision for Medical Expense Benefit: The benefits provided under the plan selected are excess to any valid and collectible coverage. In the absence of other coverage, this policy will provide primary benefits, subject to the deductible. 11.2. Procedures to File a Soccer Injury Claim (Medical)

11.2.1. Our claim form is required. Injured party is to obtain an insurance claim form from the local Insurance Commissioner.

11.2.2. Injured party, or parents or guardians, must complete the form. All signatures must be affixed in the proper sections. Attach all bills.

11.2.3. The recommended filing for medical claims is within 90 days of the accident. Claim need not be delayed waiting for all bills, final release by the doctor, or an explanation of benefits (if there is primary insurance).

11.2.4. If there is primary insurance, a statement of what the primary company has paid must be sent. Payments will not be sent until the explanation of benefits has been received.

11.2.5. Claim form with all bills attached must be returned to the ASSOCIATION Insurance Commissioner for verification of information.

11.2.6. When verified, the Association Insurance Commissioner signs and dates the claim form and forwards it to the State Office for processing.

11.2.7. Once the claim is on file with the insurance company, any additional bills for the same injury can be submitted without a claim form. Attach a note with the following information:

a. STYSA b. Name of injured party c. Date of injury d. Claim on file

These may be sent directly to the State Office or the insurance company.

Liability Insurance

11.3. Who is covered?

Coverage is provided for the United States Youth Soccer Association, including State Associations, their leagues, teams, players, coaches, referees, sponsors, directors and officers, officials and volunteer workers while acting in behalf of the named insured. The additional interest of playing facilities may be added. There are no deductibles. Certificates of Insurance will be furnished by the insurance company to all requesting entities on an annual basis.

11.4. What are the benefits?

The plan covers potential liability including but not limited to the following:

11.4.1. All sanctioned and supervised activities necessary or incidental to conduct of practice, exhibition, regular season and post-season games.

11.4.2. The ownership, maintenance or use of soccer fields, floor and playing area.

11.4.3. Product liability, i.e., consumption or use of food, equipment and other products.

11.4.4. Year round sanctioned and supervised activities such as fund raising, meetings and awards banquets.

11.4.5. Liability assumed under contract.

11.4.6. Libel, slander, defamation of character; false arrest; wrongful eviction; and invasion of privacy.

11.4.7. Non-owned and hired automobile (limited to teams, leagues and associations).

11.4.8. Advertising injury

11.4.9. Fire legal liability

11.4.10. Incidental Malpractice Liability

11.4.11. Additional insures when added by endorsement.

11.4.12. Participant legal liability.

11.4.13. Liability Medical Expense

11.5. Procedure to File a Soccer Liability Claim

Liability claims often result from lawsuits brought on by injured spectators, injured players and / or property damaged during a sponsored event. Notify your State Office immediately since there is normally a short period of time in which to answer these lawsuits. The State Office will in turn notify the insurance carrier. The recommended filing for liability claim is within 30 days.

The medical / liability information provided is only a very general reference to what coverage(s) the insurance policy or policies provides and is not intended to attempt to describe all of the various details pertaining to the insurance. Actual coverages detailed in the policy of insurance are always subject to all terms, provisions, conditions, and exclusions as contained therein. You should not rely upon this generalized summary, but should consult your Association Insurance Commissioner or the State Office for additional information.

1

Dear STYSA Registered Member, Parent or Guardian, This letter outlines the procedures for filing a medical claim for a soccer injury. If you have any questions in regards to filling out this form please contact the STYSA office at the number above. If you are submitting a claim for an injury that happened prior to September 1, 2016, please contact the STYSA office for the correct claim form.

1. Pullen Insurance Company form must be completed the within 90 days of the injury. 2. Attach any itemized bills. 3. This cover letter must be signed by the claimant’s Home Association Insurance

Commissioner. If this cover letter is not signed by the home association Insurance Commissioner, the entire claim will be sent back to the parent. A listing of current Association Insurance Commissioners are listed on the STYSA website at www.stxsoccer.org

4. Mail this instruction letter along with the completed claim form to the STYSA office. If you have not submitted this claim form DO NOT mail any forms directly to the insurance company.

Association Insurance Commissioner Verification

Association Name: Club Name: Players Name: DOB: Player ID # Signature of Association Insurance Commissioner: Date:

South Texas Youth Soccer Association

15209 Hwy. 290 E Manor, TX 78653

Phone (512) 272-4553 Fax (512) 272-5167

www.stxsoccer.org/forms_and_documents

This policy provides for coverage for registered players, coaches, trainers, and other officials, during sanctioned events including regularly scheduled practices and games. For players or members who have health insurance coverage this insurance acts as secondary coverage. For players or members that do not have other health insurance coverage, this

coverage acts as primary insurance

Do’s and Don’ts Do

Do read the explanation of benefits Do be prepared to pay a deductible Do request itemized bills from medical providers

Do submit completed paperwork, as outlined below immediately to start the claim process

Don’t

Don’t wait until you have received bills or an EOB to submit your claim Don’t list South Texas Youth Soccer Association as the Insurer Don’t submit forms without required signatures Don’t submit initial claim forms to Pullen Insurance Services

Signatures Required: * In addition to fully completing each section, all pages must have their corresponding signatures

State Office (Section IV) signature will be completed once all paperwork is provided with signatures from Local Association Insurance Commissioner, Coach/Official and Parent/Guardian/Claimant.

Page 1 (Association Insurance Commissioner Verification)

Signature of Local Association Insurance Commissioner

Page 2 (Injury Information)

Section III – Coach or Local Official signature; including name printed and date signed

Section IV – State Office (STYSA) once all pages have been completed and signed (last signature)

Page 3 (Insurance Information) * This page has to be filled out even if you are using this as a primary/only means of insurance

Signature of Parent/Guardian/Claimant

Insurance Submission Process: * Parent/Guardian or Claimant should fill out each section and page completely before submitting

Parent/Guardian/Claimant gives completed forms to Coach or Local Official to sign

Coach or Local Official signs Section III and gives to Local Association Insurance Commissioner to sign

Local Association Insurance Commissioner will sign and send completed forms to State Association (STYSA)

State Association (STYSA) will process, sign and send to Pullen to initiate the claim process

Pullen will process the claim and contact the Parent/Guardian or Claimant directly via mail with two-three weeks o Once a claim has been initiated claimant will work with Pullen/Mutual of Omaha directly

www.stxsoccer.org/forms_and_documents

ACCIDENT MEDICAL INSURANCE

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

SOUTH TEXAS YOUTH SOCCER ASSOCIATION ACCIDENT MEDICAL CLAIM FORM

GUIDELINES FOR SUBMITTING A YOUTH SOCCER ACCIDENT CLAIM FORM

1. Complete ALL questions on the Youth Soccer Accident Claim Form.

2. Have the coach or another local official that witnessed the accident sign Section III (COACH OR LOCAL OFFICIAL VERIFICATION).

3. Sign the claim form in Section VI (STATEMENT OF CERTIFICATION/AUTHORIZATION TO RELEASE INFORMATION.)

4. File this new report of claim within 90 days of the date of accident or as soon thereafter as is reasonably possible.

5. If you have other insurance, submit your itemized bills to the other carrier first. You will receive a payment Explanation of Benefit worksheet (EOB) from your other carrier. Do NOT wait until your other carrier has processed all your bills before filing a Youth Soccer Accident Claim Form.

6. You may attach itemized bills and your other carrier’s EOBs that are ready at the time of submitting this Claim Form.

7. Send the Claim Form to your State Association for verification and authorized state signature. DO NOT SEND THE CLAIM FORM DIRECTLY TO PULLEN INSURANCE SERVICES.

8. Upon receipt of the claim form from your state association we will forward an acknowledgement form advising you of receipt of your claim. All future correspondence concerning your claim should be directed to Mutual of Omaha at the address and phone number listed on your acknowledgement.

HELPFUL REMINDERS

1. There is a $1,000 deductible per covered accident for the 9/1/16 - 9/1/17 policy year. Each claim is also subject to the application of a 70/30 co-insurance provision with a $50 physical therapy/chiropractic limit per visit/$2,000 total maximum. Failure to follow the rules of your primary healthcare coverage will result in a benefit reduction of eligible expenses to 50% of the amount otherwise payable.

2. Each itemized bill MUST show the following:

• Provider of Service’s Name • Date of Service • Provider’s Address • Diagnosis Description or Codes (ICD-9) • Provider’s Federal Tax ID# • Procedure Description or Codes (CPT) • Provider’s Telephone # • Charge for each Procedure

3. Additional bills to be submitted at a later date (after the initial submission of your claim) should be mailed directly to Mutual of Omaha with the following information: Name of the claimant, date of the accident, and name of the State Youth Soccer Association.

4. Please allow time to properly process your claim.

5. Please respond promptly to any correspondence requesting additional information. It is the Parent / Guardian / Claimant’s responsibility to request this information from the provider of service or from your primary carrier.

6. An Explanation of Benefits will be sent to you by Mutual of Omaha.

MOST FREQUENTLY ASKED QUESTIONS

What is an itemized bill? An itemized bill is a detail of the procedures performed by a licensed provider of service; i.e. Hospital, Clinic, Physician, etc.

What if I don’t have an itemized bill? The Parent/Guardian must request this information from the provider of service. Some providers only mail a balance due statement. Mutual of Omaha is unable to process this charge without an itemized bill. Again, request this information from the provider service. Explain that you have Youth Soccer Excess Accident Coverage.

Can you process this claim with my other insurance carrier’s worksheet alone? No, the Payment Explanation (EOB) from your other insurance does not have complete information to process this claim.

What if I don’t have my other carrier’s payment explanation (EOB)? The Parent/Guardian must request the EOB from their other insurance carrier.

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

POLICY NUMBER: SR2014TX-P-053272 POLICY YEAR: 9/1/16 – 9/1/17 SECTION I TO BE COMPLETED BY CLAIMANT, PARENT OR GUARDIAN 1. Name: (LAST) (FIRST) (MIDDLE) 2. Date of birth: / / 3. Sex: Male Female 4. Home Address: (STREET) (CITY) (STATE) (ZIP CODE) 5. Type of claimant: Player Coach/Asst Coach Other: 6. Accident date: / / 7. Description of injury (Indicate LEFT or RIGHT; i.e. Left Leg): 8. Did accident occur during ( all that apply) game practice tournament indoor soccer

sanctioned/sponsored activities travel directly and interruptedly to or from activity premises 9. Describe how injury was sustained: ____ 10. Name of field / facility where accident occurred: SECTION II STATISTICAL INFORMATION 1. Name of local association or league: 2. Name of club (if applicable): 3. Name of team: 4. Age Division: (U-12, U-10, etc): 5. Competitive Recreational 6. Time: Morning Afternoon Evening After Hours 7. Location: On Field Sidelines Spectator Area Other 8. Disposition: On-site Care Only Ambulance Personal Refused care transportation

9. Surface: Dirt Grass Artificial Turf Other

10. Surface condition: Dry Wet Icy Irregular

11. Position: Goalie Forward Defender Other

12. Activity: Running w/ ball Running w/o ball Defending Other

13. Situation: Hit by ball Collision w/ Non-contact Other Participant injury

SECTION III COACH OR LOCAL OFFICIAL VERIFICATION

Signature of Coach or Local Official Coach or Local Official Name (print) Date

SECTION IV AUTHORIZED STATE OFFICIAL *

I, _______________________________________, of the __________________________________ certify that the above claimant was a registered player, coach, assistant coach, or participant at the time the accident occurred.

Signature of Authorized State Official Title Date

* Must be signed by the authorized state soccer association administrator with the state soccer office.

IMPORTANT This claim form must be mailed to your state association listed below:

South Texas Youth Soccer Association

15209 Highway 290 East Manor, Texas 78653

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

CLAIMANT’S NAME:

FAILURE TO COMPLETE THIS FORM MAY RESULT IN UNNECESSARY DELAY IN THE PROCESSING OF THIS CLAIM.

SECTION V PARENT / GUARDIAN / CLAIMANT INFORMATION Father / Guardian / Claimant Mother / Guardian / Claimant

Name: Name:

Address: Address:

City: City:

State: Zip: State: Zip:

Home Phone: ( ______ ) ______ - ______ Home Phone: ( ______ ) ______ - ______

Employer: Employer:

Phone: ( ______ ) ______ - ______ Ext. Phone: ( ______ ) ______ - ______ Ext.

Email: Email:

Is claimant covered under ANY other insurance policy? Yes No

Company Name:

Address:

City: State: Zip:

Phone: ( ______ ) ______ - ______

Insured Name:

Insured ID #: Insured Group # / Name: If your son or daughter has medical insurance coverage as an eligible dependent from a previous marriage as mandated in a divorce decree, please give name, address and phone number of responsible party:

SECTION VI STATEMENT OF CERTIFICATION/AUTHORIZATION TO RELEASE INFORMATION Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. I hereby authorize any physician, hospital, or other medically related facility, insurance company, or other organization, institution or person that has any records or knowledge of me, and/or the above named claimant, to disclose, whenever requested to do so by Mutual of Omaha or its representative, any and all such information. A photocopy of this authorization shall be considered as effective and valid as the original.

Signature of Parent / Guardian / Claimant Date

SECTION VII ASSIGNMENT OF BENEFITS

ALL BENEFITS WILL BE MADE PAYABLE TO DOCTORS AND HOSPITALS INVOLVED, UNLESS ACCOMPANIED BY PAID RECEIPTS.

Coverage Underwritten by:

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

SOUTH TEXAS YOUTH SOCCER ASSOCIATION FORMULARIO DE RECLAMO MÉDICO DE ACCIDENTE

PAUTAS PARA SOMETER UN YOUTH SOCCER ACCIDENT CLAIM FORM 1. Complete TODAS LAS preguntas en el Youth Soccer Accident Claim Form. 2. Haga firmar LA SECCIÓN III (VERIFICACIÓN DEL ENTRENADOR O DIRIGENTE LOCAL) por el entrenador u

otro dirigente local que presenció el accidente. 3. Firme el formulario de reclamo en la SECCIÓN VI (DECLARACIÓN DE CERTIFICACIÓN/AUTORIZACIÓN PARA

HACER PÚBLICO LA INFORMACIÓN.) 4. Someta este nuevo reporte de reclamo dentro de un período de 90 días de la fecha del accidente o lo más pronto

que es razonablemente posible a partir de entonces. 5. Si tiene otro seguro, someta sus facturas médicas detalladas a la otra compañía primero. Recibirá una hoja de

Explicación de Beneficios de pago (EOB) de su otra compañía. NO espere hasta que su otra compañía haya tramitado todas sus facturas antes de someter un Youth Soccer Accident Claim Form.

6. Usted puede conectar las facturas detalladas y EOBs de la otra compañía que estén listos en el momento de enviar este formulario.

7. Envíe el Formulario de reclamo a su Asociación Estatal para verificación y la firma autorizada estatal. NO ENVÍE EL FORMULARIO DE RECLAMO DIRECTAMENTE A PULLEN INSURANCE SERVICES.

8. En el momento de recibir su formulario de reclamación de la Asociación del estado, le enviaremos un formulario en el cual nos acusará recibo de su reclamación. Toda la correspondencia futura relacionada con su reclamo debe orientarse a Mutual of Omaha en el dirección y número de teléfono indicado en nuestra correspondencia en la que señaló usted recibo de su información.

RECORDATORIOS PRẤCTICOS

1. Hay un deducible de $1,000 por cada accidente cubierto durante el año de la póliza del 9/1/16 hasta el 9/1/17. En adición, cada reclamo es sujeto a la aplicación de una estipulación de un co-seguro proporcional de 70/30 con un límite en cuanto a terapia física de $50 cada visita con un máximo total de $2,000. Incumplimiento de la normativa de su cobertura de atención médica primaria resultará en una reducción del beneficio de gastos elegibles al 50% de la cantidad a pagar de otro modo.

2. Cada factura detallada DEBE mostrar lo siguiente:

3. Las facturas adicionales que deben ser sometidas en una fecha posterior (después de la sumisión inicial de su reclamo) deben ser enviadas directamente a Mutual of Omaha, con la siguiente información: Nombre del reclamante, fecha del accidente, y el nombre de la State Youth Soccer Association.

4. Favor de dar tiempo suficiente para tramitar debidamente su reclamo. 5. Favor de responder puntualmente a toda correspondencia que pide información adicional. Es la

responsabilidad del Padre / Tutor / Reclamante de solicitar esta información del proveedor de servicio o de su compañía de seguro primario.

6. Una Explicación de Beneficios le será enviada por Mutual of Omaha. LAS PREGUNTAS MẤS FRECUENTES

¿QUÉ ES UNA FACTURA DETALLADA? Una Factura Detallada es un desglose de los procedimientos desempeñados por un proveedor de servicio autorizado; i.e. Hospital, Clínica, Médico, etc..

¿SI NO TENGO UNA FACTURA DETALLADA? El Padre/Tutor/ debe solicitar esta información del proveedor de servicio. Algunos proveedores envían solamente un estado de saldos adeudados. Mutual of Omaha no puede tramitar este cobro sin una factura detallada. De nuevo, solicite esta información del proveedor de servicios. Explique que tiene una Cobertura en Excedente de Accidentes de Fútbol de Jóvenes.

¿PUEDE TRAMITAR ESTE RECLAMO SOLAMENTE CON LA HOJA DE EXPLICACIÓN DE BENEFICIOS (EOB)DE MI OTRA COMPAÑÍA DE SEGUROS? No, la Explicación de Beneficios/Pago (EOB) de su otra compañía de seguros no tiene la información completa para poder tramitar este reclamo. ¿SI NO TENGO LA EXPLICACIÓN DE BENEFICIOS (EOB) DE MI OTRA COMPAÑÍA DE SEGUROS?

El Padre/Tutor debe solicitar la Explicación de Beneficios (EOB) de su otra compañía de seguros.

• El Nombre del Proveedor de Servicios • La Fecha del Servicio • La Dirección del Proveedor • La Descripción o Códigos (ICD-9) del Diagnosis • El No de Identificación de Impuestos Federales del Proveedor

• La Descripción o Códigos (CPT)) del Procedimiento

• El No Telefónico del Proveedor • El Cobro por cada Procedimiento

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

NO DE PÓLIZA: SR2014TX-P-053272 POLICY YEAR: 9/1/16 – 9/1/17

SECCIÓN I A SER COMPLETADO POR EL RECLAMANTE, PADRE, O TUTOR 1. Nombre:(APELLIDO/S) (NOMBRE) (SEGUNDO NOMBRE) 2. Fecha de nacimiento: _ / / 3. Sexo: Masculino Femenino 4. Dirección Particular: (CALLE) (CIUDAD) (ESTADO) (CÓDIGO POSTAL) 5. Tipo de Reclamante: Jugador Entrenador/Entrenador Adjunto Otro: 6. Fecha del Accidente:____ / ____ / ____ 7. Descripción de la lesión (indique IZQUIERDO o DERECHO; por ejemplo. Pierna izquierda): 8. El accidente ocurrió durante: (√ todo que se aplica) juego práctica torneo fútbol en campo techado

actividades sancionadas/patrocinadas viaje directo y sin interrupción a o de la local de la actividad 9. Describir cómo se sostuvo lesions: _____ 10. Nombre del campo/facilidad donde ocurrió el accidente:

SECCIÓN II INFORMACIÓN ESTADÍSTICA 1. Nombre del asociación o liga local: 2. Nombre del club (si se aplica): 3. Nombre del equipo: 4. División de edad: (U-12, U-10, etcétera): 5. Competitivo Recreativo 6. Hora: Mañana Tarde Noche Fuera de Horas 7. Lugar: En el Campo Zona que rodea el Área de los Otro área del Campo Espectadores 8. Disposición: Cuidado In Situ Ambulancia Transporte Personal Cuidado

Rehusado Solamente 9. Superficie: Tierra Hierba Hierba Artificial Otro 10. Condición de la : Seca Mojada Cubierta de Hielo Irregular Superficie 11. Posición: Portero Delantero Defensa Otro

12. Actividad: Corriendo con la pelota Corriendo sin la pelota Defensa Otro 13. Situación: Golpeado por la pelota Colisión con un Lesión sin contacto Otro Participante

SECCIÓN III VERIFICACIÓN DEL ENTRENADOR O DIRIGENTE LOCAL

Firma del Entrenador o Dirigente Local Nombre del Entrenador o Dirigente Local (en letras grandes)

Fecha

SECCIÓN IV DIRIGENTE ESTATAL AUTORIZADO*

Yo, ______________________________, de la certifico que el reclamante ya indicado era un jugador, entrenador, entrenador adjunto o participante registrado en el momento que ocurrió el accidente.

Signature of Authorized State Official Title Date

*Debe ser firmado por el administrador autorizado de la asociación estatal de fútbol con la oficina de la asociación estatal de fútbol

IMPORTANTE ESTE FORMULARIO DE RECLAMO DEBE SER ENVIADO A SU

ASOCIACIÓN ESTATAL INDICADO ABAJO: South Texas Youth Soccer Association

15209 Highway 290 East Manor, Texas 78653

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 FAX (817) 738-2993 PULLENINS.COM

NOMBRE DEL RECLAMANTE:

EL INCUMPLIMIENTO DE ESTE FORMULARIO PUEDE CAUSAR UNA DEMORA INNECESARIA DEL TRÁMITE DE ESTE RECLAMO.

SECCIÓN V INFORMACIÓN DEL PADRE / TUTTOR / RECLAMANTE Padre / Tutor / Reclamante Madre / Tutor / Reclamante

Nombre: Nombre:

Dirección: Dirección:

Ciudad: Ciudad:

Estado: Código Postal: Estado: Código Postal:

Teléfono particular: ( ______ ) ______ - ______ Teléfono particular: ( ______ ) ______ - ______

Empleador: Empleador:

Teléfono: ( ______ ) ______ - ______ Ext. Teléfono: ( ______ ) ______ - ______ Ext.

Dirección de Email: Dirección de Email:

¿Se cubre el reclamante bajo CUALQUIER otra póliza de seguros? Sí No

Nombre de la Compañía:

Dirección:

Ciudad: Estado: Código Postal:

Teléfono: ( ______ ) ______ - ______

Nombre del Asegurado:

No: de Identificación del Asegurado: No /Nombre del Grupo Asegurado: Si su hijo o hija tiene cobertura de seguro médico por causa de ser un dependiente elegible de un casamiento previo bajo un mandato que hace parte de un decreto de divorcio, favor de indicar el nombre, dirección y número telefónico de la parte responsable:

SECCIÓN VI DECLARACIÓN DE CERTIFICACIÓN/AUTORIZACIÓN PARA HACER PÚBLICO LA INFORMACIÓN Cualquier persona que a sabiendas presente una reclamación falsa o fraudulenta para el pago de una pérdida es culpable de un delito y puede ser sujeta a multas y reclusión en la prisión estatal.

Por la presente, autorizo a cualquier medico, hospital, u otra facilidad relacionada médicamente, compañía de seguros, u otra organización, institución o persona que tiene cualquier registro o conocimiento de mi, y/o del dicho reclamante, para revelar, cuando se lo solicitara por Mutual of Omaha o su representante, cualquier y toda información de ese tipo. Una fotocopia de esta autorización será considerada tan efectiva y válida como el original.

Firma del Padre/Tutor/Reclamante Fecha

SECCIÓN VII ASIGNACIÓN DE BENEFICIOS TODOS LOS BENEFICIOS SE HARÁN PAGADEROS A LOS MÉDICOS Y HOSPITALES INVOLUCRADOS, A MENOS QUE SE ACOMPAÑEN POR RECIBOS PAGADOS.

Cobertura seleccionada por :

South Texas Youth Soccer Association

(Underwritten by An A.M. Best Rated “A” Insurance Company)

YOUTH SOCCER GENERAL LIABILITY BENEFITS

Explanation of Coverage Term of Insurance: September 1, 2016 to September 1, 2017

ACCIDENT MEDICAL EXPENSE BENEFITS & ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Explanation of Coverage Term of Insurance: September 1, 2016 to September 1, 2017

Who is Covered? South Texas Youth Soccer Association, its affiliated associations, leagues, clubs and all officers, directors, coaches, employees, teams, team officials, and volunteers while acting on behalf of South Texas Youth Soccer Association at a covered activity.

Limits of Liability General Aggregate NONE (Unlimited) Products/Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Each Occurrence $1,000,000 Participant Legal Liability Each Occurrence (other than brain injury) $1,000,000 Participant Legal Liability Aggregate (other than brain injury) Unlimited Participant Legal Liability Brain Injury Each Occurrence $2,000,000 Participant Legal Liability Brain Injury Aggregate $5,000,000 Damage to Premises Rented to You Limit $300,000 Medical Expense (Spectators Only) $5,000 Sexual Abuse Each Occurrence $1,000,000 Sexual Abuse Aggregate $2,000,000 Non-Owned / Hired Auto Liability $1,000,000 Excess Liability $4,000,000 subject to policy exclusions

What is Covered? Liability for bodily injury or property damage to spectators, game participants, and to members of the general public for activities

sanctioned by South Texas Youth Soccer Association. Liability for outdoor fields owned by affiliates for its sole use while acting on behalf as a member of the state association. Fundraising, meetings, awards banquets. Activities necessary or incidental to the conduct of practice, exhibition, post season and scheduled games. Liability for false arrest, detention or malicious prosecution, libel, slander, defamation of character, or wrongful eviction. Hired and non-owned auto, while being used in the business of the named insured. Excludes coverage for any driver transporting

athletic participants. Products liability for food or drinks sold on premises. Medical Payments $5,000 (non-participants). Host Liquor liability for banquets and meetings.

Territory Worldwide for bodily injury, property damage, and personal and advertising injury while temporarily outside of the United States providing suit is made within the United States.

Notable General Liability Exclusions Standard commercial general liability exclusions apply. Property of others in the care, custody and control of the insured such as personal property of players, coaches, or parents. Liability to pay Worker's Compensation. Intentional acts. Amusement devices other than inflatables and dunk tanks.

Additional Insured Certificates of insurance are furnished to each association identifying them as members of the state organization. Certificates of insurance will be issued upon request adding the name of a school district, university, private land owner, municipality, or sponsor. All other requests are subject to underwriting approval.

Who is Covered? Insured persons include all registered team members, those players participating in approved try-outs, coaches, managers, referees, officials, and volunteers of the teams, leagues or of the association.

Covered Activities Insured persons are covered for injuries resulting directly and independently of all other causes from accidents occurring while participating in the following covered activities: Scheduled games, team practice sessions, tryouts or sponsored activities provided they are under the direct supervision of a team

official; or sanctioned local or national tournaments as a member of a contestant team. Organized and supervised group travel as authorized by the Policyholder directly to and from a covered event.

What Is Not Covered? The plan does not provide coverage for: intentionally self-inflicted injury air travel except as a fare-paying passenger on a regularly scheduled airline on a scheduled flight injuries resulting from other than covered activities loss resulting from sickness or disease, except bacterial infection which occurs through an accidental wound

Accident Medical Policy Limits For reasonable necessary medical expenses, our youth accident medical policy pays up to $100,000 for injuries sustained in a covered accident. Dental injuries are treated like any other injury. Payment will not be made for any expenses incurred after 52 weeks from the date of injury. An expense is considered incurred on the date the medical care is rendered. A $1,000 Deductible and 70/30 Co-Insurance applies to each covered accident. A Physical Therapy/Chiropractic limit of $50 per visit/$2,000 maximum per injury also applies.

South Texas Youth Soccer Association excess accident medical insurance policy is secondary insurance. Failure to follow the rules of your primary healthcare coverage will result in a benefit reduction of eligible expenses to 50% of the amount otherwise payable.

"Injury" means bodily injury of an Insured Person resulting directly and independently of all other causes from an accident which occurs while he or she is participating in a covered activity. Sickness or disease (except pus forming infections which occur through an accidental cut or wound) of any kind will not be considered as bodily injury.

Reasonable Expenses means usual and customary charges.

Accidental Death and Dismemberment Benefits The plan pays: $10,000 for loss of life or loss of two or more members, which results from injuries sustained in an accident which occurred while

participating in a covered activity. $2,500 for loss of one member (hand, foot or eye), which results from injuries sustained in an accident which occurred while

participating in a covered activity. Such payment shall be in addition to any other indemnity payable to the date of loss, but only one amount, the larger amount

applicable shall be payable for all such losses resulting from any one accident. "LOSS" shall mean, with respect to hands and feet, physical separation through or above the wrist or ankle joint; with respect to

the eyes, entire and irrecoverable loss of sight.

Excess Coverage The participant accident medical expense insurance is provided on an "excess" basis. This means that after the insured player or coach has been reimbursed for medical expenses by other insurance programs, and after the deductible has been satisfied, the Youth Soccer Accident Medical Expense plan will pay up to the maximum Medical Expense benefit for remaining treatment, service and supply expenses. These other programs include group, blanket or franchise health insurance coverage, group hospital or medical service plans, and prepayment coverage; any coverage under labor-management trustee plans, union welfare plans, employer organization plans, and coverage under any governmental programs, coverage required or provided by any statute, and automobile reparations insurance (no-fault) coverage.

Claim Procedures For AD&D and Accident Medical Expense Claims, claim forms are available through your State Association, League or Club Offices. Detailed Accident Medical Expense claim instructions can be found on each claim form. In the event of injury requiring medical treatment, you should: Fully complete a claim form verified by a witness and submit it to your State Soccer Association for verification. Notice of claims must be filed within 90 days from the date of injury or as soon thereafter as is reasonably possible. Youth Soccer Accident Medical coverage is provided on an "excess" basis. Therefore, charges must first be submitted to any other medical insurance carrier available to the participant.

THIS OUTLINE IS ONLY FOR GENERAL INFORMATION AND NONE OF THE ABOVE SHALL AMEND OR ALTER THE INSURANCE CONTRACTS. THE WORDING OF THE POLICIES CONSTITUTES THE ONLY AGREEMENT BETWEEN THE INSURED AND THE INSURANCE COMPANY. CONSULT YOUR POLICIES FOR COVERAGE EXCLUSIONS.

2560 RIVER PARK PLAZA, SUITE 300 FORT WORTH, TEXAS 76116

(817) 738-6100 PULLENINS.COM

STYSA Insurance Overview

Summer GBM2016

Commercial General Liability-Bodily Injury -Personal Injury-Property Damage

Accident Participant Medical-Supplemental Accident Coverage for Players and Coaches

Non-Profit Liability (D&O)-Wrongful Acts, Errors, Omissions

STYSA Provides Member Affiliates

Each Occurrence Limit: $5,000,000General Aggregate Limit: UnlimitedParticipant Legal Liability Each Occur. (Non-Brain Injury): $5,000,000Participant Legal Liability Aggregate (Non-Brain Injury): UnlimitedParticipant Legal Liability Each Occur. (Brain Injury Only): $2,000,000Participant Legal Liability Aggregate (Brain Injury Only): $5,000,000Sexual Abuse / Molestation Each Occurrence: $5,000,000 Sexual Abuse / Molestation Aggregate: $6,000,000

Note: Brain Injury Limits Inclusive of Defense Costs

Combined General Liability & Excess Liability Limits

∗ $100,000 Maximum per injury∗ $1,000 Deductible per injury∗ 70/30 Coinsurance∗ Physical Therapy - $50 per visit / $2,000 max∗ 52 week benefit period∗ Excess coverage∗ Must follow rules of primary healthcare plan or

benefit reduction of 50% applies∗ $10,000 Accidental Death & Dismemberment Benefit

Accident Medical Limits

∗ Provides liability protection for wrongful acts attributed to the governance of the organization

∗ Wrongful act = breach of duty, neglect, error, misstatement, misleading statement or omission

∗ Includes Employment Practices Liability & Third party Wrongful Acts

Limit of Liability$5,000,000 Shared aggregate limit of liability

Retention (Deductible)$10,000 D&O and Employment Practices retention $15,000 Third Party Wrongful Acts retention

Non-Profit Liability (Directors & Officers Liability)

Commercial Property-Protects buildings and business personal property (building contents) from physical loss

Inland Marine (Equipment Floater)-Protects equipment (soccer goals, Gators, golf carts) from physical loss

Dishonesty -Employee / Volunteer Embezzlement

STYSA Does Not Provide

∗ Portable Goal Safety∗ Sexual Abuse Awareness & Prevention∗ Concussions (Traumatic Brain Injury)

*Education is the Key*

Important Risk Management Topics

Feel free to contact me if you have any questions

Phone: (817) 738-6100Email: dpullen@pullenins.com

Questions?