| Insurer: | National Union Fire Insurance Company of Pittsburgh, PA |
|---|---|
| Policy Number: | SRG 0009156189 |
| Benefit: | Accidental Death and Dismemberment |
| Accidental Medical/Dental Expense | |
| Description of Class: | Class 1: All active cheerleading student athletes, student trainers, student managers, and student coaches of the Policyholder. |
| Covered Sports: | Cheerleaders, Mascots & Dance participants |
| Description of Activity: | Coverage is provided for all cheerleaders, dance team members, and mascots, for all campuses of the University of Wisconsin State College System while participating as a member of a Policyholder team during spirit competitions, practice, alumni events, charity events, or any activity not related to a specific sport event. |
| Definition of Covered Injury: | Injury: Means bodily injury caused by an accident that : (1) occurs while this Policy is in force as to the person whose injury is the basis of claim; (2) occurs while such person is participating in a Covered Activity; and (3) results directly and independently of all other causes in a covered loss. |
| Notice of Claim: | Written notice of claim must be given to the Company within 20 days after an Insured’s loss, or as soon thereafter as reasonably possible. Notice given by or on behalf of the claimant to the Company at A&H Claims Department, PO Box 25987, Shawnee Mission, KS 66225, with information sufficient to identify the Insured, is deemed notice to the Company. |
| Claim Forms | The Company will send claim forms to the claimant upon receipt of a written notice of claim. If such forms are not sent within 15 days after the giving of notice, the claimant will be deemed to have met the proof of loss requirements upon submitting, within the time fixed in this Policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. The notice should include the Insured’s name, the Policyholder’s name and the Policy number. |
| Proof of Loss | Written proof of loss must be furnished to the Company within 90 days after the date of the loss. If the loss is one for which this Policy requires continuing eligibility for periodic benefit payments, subsequent written proofs of eligibility must be furnished at such intervals as the Company may reasonably require. Failure to furnish proof within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required. |
| AD&D Benefit: $10,000 Class 1 | ||
| Accidental Loss of: | Percent of Loss of Life Benefit Amount | |
| Life | 100% | |
| Both Hands, or Both Feet | 100% | |
| Sight of Both Eyes | 100% | |
| One Hand and One Foot | 100% | |
| One Hand and the Sight of One Eye | 100% | |
| One Foot and Sight of One Eye | 100% | |
| One Hand, or One Foot | 50% | |
| The Sight of One Eye | 50% | |
| Speech or Hearing in Both Ears | 50% | |
| Hearing in One Ear | 25% | |
| Thumb and Index Finger of Same Hand | 25% |
| Excess Accidental Medical Expense: | Class 1-Covered Activities |
|---|---|
| $5,000,000: Maximum Amount (10 year Benefit Period) | |
| $75,000: Deductible per Accident- must be met within 2 years of the Accident | |
| Catastrophe Cash Benefit Maximum: | $500,000: $100,000 Lump Sum, $3,333.33/mo for 120 months max |
| Aggregate Limit of Insurance: | $500,000 |
| Major Exclusions: | suicide or any attempt at suicide or intentionally self inflicted injury or any attempt at intentionally self inflicted injury. |
| sickness, disease or infections of any kind; except bacterial infections due to an accidental cut or wound, botulism or ptomaine poisoning. | |
| the Insured’s commission of or attempt to commit a felony. | |
| declared or undeclared war, or any act of declared or undeclared war. | |
| participation in any team sport or any other athletic activity, except participation in a Covered Activity. | |
| full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned Premium for any period for which the Insured is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded.) | |
| travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured is:
a. riding as a passenger in any aircraft not licensed for the transportation of passengers for hire. b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft. |
|
| any condition for which the Insured is entitled to benefits under any Workers’ Compensation Act or similar law. | |
| the Insured being under the influence of drugs or intoxicants, unless taken under the advice of a Physician. |
DISCLAIMER
This insurance document is furnished to you as a matter of information for your convenience. It only summarizes the listed policy(ies) and is not intended to reflect all the terms and conditions or exclusions of such policy(ies). Moreover, the information contained in this document reflects coverage as of the effective date(s) of the policy(ies) and does not include subsequent changes. This document is not an insurance policy and does not amend, alter or extend the coverage afforded by the listed policy(ies). The insurance afforded by the listed policy(ies) is subject to all the terms, exclusions and conditions of such policy(ies).