I NSURANCE

CatholicMutualPARTICIPANT ACCIDENTINSURANCE CLAIM FORM

(NOTETotheParticipant/Parent/Guardian: ReportandClaimFormwillbereturnedifnotfullycompletedandsigned.)

BasicProceduresforSubmittingtheIncidentReportandParticipantAccidentInsuranceClaimForm

1.TheParish/SchoolAdministratororPastorwillcompletetheincidentreport,signanddatewhereindicated.

2.Theparticipantorparticipant'sparents/guardianwillcompletetheAccidentMedical/InsuranceClaimform.

3.ForwardthecompletedIncidentReportandAccident Medical/InsuranceClaimformstoK&KInsuranceGroup.BOTHreportsshouldbesubmittedtoK&Katthesametime.

PLEASENOTE:ProcessingmaybedelayediftheReportandAccidentMedical/InsuranceClaimformsarenotfullycompleted,signedandsenttogether.

TotheParticipant/Parent/Guardian:

Attachcurrentitemizedphysician,hospital,orotherprovider'sbillsforaccidentmedicalexpensesbeingclaimedaswellastheprimarycarrier'sExplanationofBenefitsshowingtheirpaymentsanddenials.Thesebillsmustshowthepatient'sname,condition(diagnosis),typeoftreatmentgiven,datetheexpensewasincurredandthechargesmade.

MAILTO:

K&KINSURANCEGROUP,INC.

ClaimsDepartment

P.O.Box2338

FortWayne,Indiana 46801-2338(800)237-2917

Forgeneralclaimsquestionsorstatusofaclaimcall:

800-237-2917,option1.orefax:312-381-9077

Departmentemail:(tobeusedwhenforwardingnewclaimsandattachmentsforexistingclaims)

KI N S

U R A KN C E

1712MagnavoxWay P.O.Box2338FortWayne,Indiana46801

CatholicMutual

ph(800)237-2917

Fax(260)459-5915forParticipantAccidentUnit

OnbehalfofNationwideInsurance(PLEASE PRINT)

INCIDENTREPORT

INSUREDNAMEOFINSURED:DioceseofBaker(SludenlAccidenl/CAT)POLICY#:FPX0000025473200FPX0000025472600

PARISH/SCHOOL:CITY/STATE:

TIMEPLACEDATE:TIME:DAM0PM

OFINCIDENTACTIVITY: EVENT TYPE: LOCATION:

HAPPENEDTONAME:SSN:

DATEOFBIRTH:SEX:0Male OFemalePHONE:!\ADDRESS: CITY: STATE: ZIP:

FUNCTIONAS: 0PARTICIPANT0VOLUNTEER0STUDENT

0OTHER:

APPARENTBODYPART:

INJURYCONDITION:(Laceration,Concussion,Sprain,Fracture,Etc.):ORDAMAGE 0ON-SITECAREONLY,BY(PHYSICIAN)(EMn(TRAINER)OTHER: 0AMBULANCE,TAKENTO: CITY:

0FATALITY

OCCASIONWHATWASTHESITUATIONAND EXACTLOCATIONATTHETIMEOFTHE INCIDENT?

INCIDENTDESCRIBEWHAT HAPPENED:

DESCRIPTION

WITNESSES / NAME: / NAME:
(Ifknown) / ADDRESS: / ADDRESS:

PHONE:I \PHONE:I\

PASTOR/PARISH/NAME:PHONE:I\

SCHOOLTITLE:ORGANIZATION:

ADMINISTRATORSIGNATURE:DATE:

COMPLETEALLSECTIONSANDFAXORMAILIMMEDIATELYTO:

K&KINSURANCEGROUP,INC.,P.O.BOX2338,FORTWAYNE,IN46801-2338

THISFORMMUSTINCLUDETHEINSUREDNAME,POLICYNUMBER,ANDSIGNATUREOFTHEINSURED/REPRESENTATIVEBEFORERETURNINGORPROCESSINGMAYBEDELAYED

1029_5_10CATHMUT

KI N S U R A KN C E

OnbehalfofNationwideInsurance

1712MagnavoxWay P.O.Box2338FortWayne,Indiana46801

(800)237-2917Fax(260)459-5915

email:

CatholicMutual

ACCIDENT MEDICAL INSURANCE

CLAIMFORM

InsuredName:DioceseofBaker(StudentAccidenUCAT)

PolicyNumber:FPX0000025473200FPX0000025472600

ITISIMPORTANTTHATALLINFORMATIONREQUESTEDONTHISCLAIMFORMBEFURNISHED.OMISSIONOFVITALINFORMATIONWILLCAUSEDELAYINCLAIMPROCESSING.

TOBECOMPLETEDBYINJUREDPERSONORPARENT

PARTII

MEDICALBENEFITS UNDERTHISPOLICYMAYPROVIDEPRIMARY,EXCESSORACOMBINATIONOFBOTHCOVERAGES.UPONRECEIPTOF THISCLAIMFORM,ANACKNOWLEDGEMENT LETTERWILLBESENTTOYOUADVISINGWHATSPECIFICBENEFITSYOUAREENTITLEDTO.

IFTHEMEDICALBENEFITISEXCESS,YOURCLAIMSHOULDBESUBMITIEDTOTHEINSURANCECOMPANYPROVIDINGCOVERAGETOYOUTHROUGHYOUROWNORYOURPARENT'SPERSONALHEALTHPLAN,YOUREMPLOYERORGOVERNMENTALHEALTHPLAN.AFTEROTHERINSURANCEBENEFITSHAVEBEENSUBMITTED,YOUSHOULDFORWARDACOPYOFTHEOTHERINSURANCECOMPANY'SEXPLANATIONOFBENEFITSANDTHECORRESPONDINGITEMIZEDMEDICALSTATEMENTS.IFYOURINSURANCECOMPANYDENIESBENEFITS,SENDACOPYOFTHEIRDENIAL.

WEWILLNOTPROCESSYOURCLAIMWITHOUTEMPLOYERINFORMATION.ITISIMPERATIVETHATWERECEIVEALLDATAREQUESTED.TIMELYRECEIPTOFREQUESTEDINFORMATIONWILLHELPEXPEDITEPROCESSINGOFYOURCLAIM.

INJUREDPERSON:

SPOUSE'SNAME(ifapplicable):_

FATHER·sNAME(ifinjuredisaminor)

MOTHER'SNAME(ifinjuredisaminor)_

EMPLOYER NAME:

EMPLOYERNAME:._

EMPLOYER ADDRESS:

EMPLOYERADDRESS:_

CITY:._

STATE:ZIP:

CITY:___STATE:ZIP:_

PHONE:'\

PHONE:_..______

GROUPINSURANCE COMPANY:

GROUPINSURANCECOMPANY.______

POLICYNUMBER:

POLICYNUMBER:__

INSURANCE COMPANYADDRESS:

INSURANCECOMPANYADDRESS:_

CITY.:_

STATE:ZIP:

CITY:___STATE:ZIP:__

SOCIALSECURllYNUMBER:

SOCIALSECURITYNUMBER:__

SIGNATURE:

SIGNATURE:._

IWAIVEANYPROVISIONOFLAWTOTHECONTRARYANDHEREBYAUTHORIZEK&KORITSREPRESENTATIVESTOFURNISHTOANYHOSPITAL,PHYSICIANOROTHERPERSONWHOHASATIENDEDME,AND MYINSURANCECARRIER,ANYANDALLINFORMATIONWITH RESPECTTOTHEACCIDENTALINJURYFORWHICHlAMCLAIMINGINSURANCEBENEFITS.

IWAIVEANYPROVISIONOFLAWTOTHECONTRARYANDHEREBYAUTHORIZEANYHOSPITAL,PHYSICIANOROTHERPERSONWHOHASATIENDEDME,ANDMYINSURANCECARRIEROREMPLOYER,TOFURNISHTOK&KORITSREPRESENTATIVESANYANDALLINFORMATION WITHRESPECTTOANYSICKNESSORINJURY,MEDICALHISTORY,CONSULTATION,PRESCRIPTIONS,ORTREATMENT,ANDCOPIESOFALLHOSPITAL,MEDICAL,ORINSURANCERECORDSINCLUDING,BUTNOTLIMITEDTO,INFORMATIONREGARDINGOTHERINSURANCECOVERAGES.IAGREETHATAPHOTOCOPYOFTHISAUTHORIZATION SHALLBECONSIDEREDASEFFECTIVEASTHEORIGINAL.

IUNDERSTANDTHISAUTHORIZATIONISNECESSARYTOFACILITATETHEOBTAININGANDPROVIDINGOFINFORMATIONNEEDEDTOQUICKLYPROCESSMYCLAIM.

SIGNED:_____

PleaseNote:Ifinjuredpersonisaminor,signaturemustbeofparentorlegalguardian.

DATE:_

1029_5_10CATHMUT

APPLICABLEINALASKA

Apersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveaninsurancecompanyfilesaclaimcontainingfalse,incomplete,ormisleadinginformationmaybeprosecutedunderstatelaw.APPLICABLE IN ARIZONA

Foryourprotection,Arizonalawrequiresthefollowingstatementtoappearonthisform.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossissubjecttocriminal andcivilpenalties.

APPLICABLEINARKANSAS,DELAWARE,KENTUCKY,LOUISIANA,MAINE,MICHIGAN,NEWJERSEY,

NEWMEXICO,NEWYORK,NORTHDAKOTA,PENNSYLVANIA,SOUTHDAKOTA,TENNESSEE,TEXAS,VIRGINIA,ANDWESTVIRGINIA

Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyoranotherperson,filesastatementofclaimcontaininganymateriallyfalseinformation,orconcealsforthepurposeofmisleading,informationconcerninganytact,materialthereto,commitsafraudulentinsuranceact,whichisa crime,subjecttocriminalprosecutionand[NY:substantial]civilpenalties.InLA,ME,TN,andVA,insurancebenefitsmayalsobedenied.

APPLICABLEINCALIFORNIA

For your protection, California law requires thefollowing toappearonthisform:Any personwho

knowinglypresentsafalseorfraudulentclaimforpaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.APPLICABLE IN COLORADO

It is unlawful to knowingly provide false,incomplete,ormisleadingfactsorinformationtoaninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayinclude imprisonment,fines, denial of insurance,andcivildamages.Anyinsurancecompanyoragentofaninsurancecompanywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsorinformationtoapolicyholderorclaimantforthe purposeofdefrauding or attempting to defraud the policy

holderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshallbereportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.APPLICABLE IN THE DISTRICT OFCOLUMBIA

Warning:Itisacrimetoprovidefalseormisleadinginformationtoaninsurertorthepurposeofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines.APPLICABLE IN FLORIDA

PursuanttoS.817.234,FloridaStatutes,anypersonwho,withtheintenttoinjure,defraud,ordeceiveanyinsurerorinsured,prepares,presents,orcausestobepresentedaproofoflossorestimate

ofcostorrepairofdamagedpropertyinsupportofaclaimunderaninsurancepolicyknowingthattheproofoflossorestimateofclaimorrepairscontainsanyfalse,incomplete,ormisleadinginformationconcerninganyfactorthingmaterialtotheclaimcommitsafelonyofthethirddegree,punishableas

providedinS.775.082,s.775.083,orS.775.084,

FloridaStatutes.

APPLICABLEINHAWAII

Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossorbenefitisacrimepunishablebyfinesorimprisonment,orboth.

APPLICABLEINIDAHO

Anypersonwhoknowinglyandwiththeintenttoinjure,defraud,ordeceiveanyinsurancecompany

filesastatementofclaimcontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

APPLICABLEININDIANA

Apersonwhoknowinglyandwithintenttodefraudaninsurerfilesastatementofclaimcontaininganyfalse,incomplete,ormisleadinginformationcommitsafelony.

APPLICABLEINMARYLAND

Anypersonwhoknowinglyandwillfullypresentsa

falseorfraudulentclaimforpaymentofalossorbenefitorwhoknowinglyandwillfullypresentsfalseinformationinanapplicationforinsuranceis

guiltyofacrimeandmaybesubjecttofinesandconfinementinprison.

APPLICABLEINMINNESOTA

Apersonwhofilesaclaimwithintenttodefraudorhelpscommitafraudagainstaninsurerisguiltyofacrime.

APPLICABLEINNEVADA

PursuanttoNRS686A.291,anypersonwhoknowinglyandwillfullyfilesastatementofclaimthatcontainsanyfalse,incompleteormisleadinginformationconcerningamaterialfactisguiltyofafelony.

APPLICABLEINNEWHAMPSHIRE

Anypersonwho,withpurposetoinjure,defraudordeceiveanyinsurancecompany,filesastatement

ofclaimcontaininganyfalse,incompleteormisleadinginformationissubjecttoprosecutionandpunishmentforinsurancefraud,asprovidedinRSA638:20.

APPLICABLEINOHIOAnypersonwho,withintenttodefraudorknowingthathe/sheisfacilitatingafraudagainstaninsurer,submitsanapplicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.

APPLICABLEINOKLAHOMA

WARNING:Anypersonwhoknowinglyandwithintenttoinjure,defraudordeceiveanyinsurer,makesanyclaimfortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.

APPLICABLEINRHODEISLAND

Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationfor insurance isguiltyofacrimeand

maybesubjecttofinesandconfinementinprison.

APPLICABLEINWASHINGTON

Itisacrimetoknowinglyprovidefalse,incomplete,

ormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.

FRAUDCIAIMS(2010102)

DearParticipant: Ifyouhaveanappointmentwithadoctorastheresultofasportrelatedinjury,pleaseshowthisdocumenttothedoctor'sinsurancesecretary.Youshouldbeidentifiedasamemberofthefollowing preferredprovidernetworksand/ortheiraffiliates.

DearDoctororProvider:Thisdocumentindicatesthatthispatientisaparticipantinthefollowingpreferredprovidernetworksand/ortheiraffiliates:

FtTrhestHealth

Network

--

HYGEIA

INSTRUCTIONS FOR COMPLETING THEACCIDENT INSURANCE FORMTO THE INJURED PERSON/PARENT /GUARDIAN

Totheinjuredperson/parenVguardian:

CompletepartIIofthisclaimform.Attachcurrentitemizedphysician,hospital,orotherprovider'sbillsforaccidentmedicalexpensesaswellaslheprimarycarrier'sexplanationofbenefitshowingtheirpaymentanddenial.Thesebillsmustshowthepatient'sname,condition(diagnosis),typeoftreatmentgiven,datetheexpensewasincurred,andthechargesmade.ReturnthisformtoK&KInsuranceGroup,Inc.Pleasenote:Claimformswillbereturnedifnotfullycompletedandsigned.Omissionofvitalinformationwillcauseadelayinclaimprocessing.

1029_5_10CATHMUT

1712MagnavoxWayP.O.Box2338FortWayne,Indiana46801-2338(800)637-.4757Fax(?60)459-5866

IMPORTANTINFORMATION

PLEASEREADCAREFULLY

OneofthespecializedbenefitsK&Kprovidesisourprofessionalclaimsservice. Wearepleased

tohaveyouasourclientandtoextendthisservicetoyou.

EnclosedisasupplyofCaseReportFormsforyouruseinreportingaccidentsonyourpremisesthat result in bodily injury and/or property damage. Early, accurate informationisusedbyK&KClaimspersonneltodeterminewhetheritshouldbetreatedasapotentialclaimagainstyourinsuran·ce,orasan"incident"tobefiledawayforfutureuseifneeded.

K&K'sCaseReportFormsaredesignedtohelpyoureportinformationpromptly andaccurq.tely.Theyalsopermitustogatherlosshistoryinformationforanalysisandprovidefurtheropportunitytominimizethecostofclaims.Usetheseformstoreportanyinjurytoapatronthatrequiredemergencyn:iedicalattentionand/orreferralformedicalcare.Also,includeanyinjurytoeitherthepersonorafamilymember.

Ifaseriousaccidentshouldoccur,particularlyonewithcriticalorfatalinjuries,callK&Kimmediately.Ourclaimsnumberisoperational24hoursaday,sevendaysaweekat1-800-237-2917.Thiswillenableustobecomeinvolvedimmediately,providingguidanceandadvice.

As indicated, complete the form by choosing the correct opt.ions and adding information

todescribetheoccurrence.

Itisourgoaltoworkcloselywithyoutoprovidethebestclaimserviceavailabletoday.P'leasecontactusifyouhaveanyquestions.

K&KInsuranceGroup,Inc.

114810/03

1712MagnavoxWay

P.O.Box2338

FortWayne,Indiana 46801-2338

(800)237-2917Fax(260)459-5910

CA#0334819

INCIDENT REPORTINGINSTRUCTIONS EMERGENCY PROCEDURES

EMERGENCYPROCEDURES

1.ACTION:Followyourwrittenplanandtakeappro­

priatecareofalllnjuiedpersons.

2.NOTICE:Incidentscanhappenanywhere.AdvisingK&Kassoonaspracticalafteranincidentoccurssurroundingyourevent,regardlessofthelocationoftheincidentorwhetherornotyoufeelyouareresponsibleforthebodilyinjuryorpropertydamage,isessential.Ifappropriate,anadjusterwillbeassigned Immediately.

3.STATEMENT:Donotmakeanystatementsregard­ingthecauseoftheaccident.Givenoopinionsorconjecturestoanyoneotherthanyourinsurancecompanyrepresentative.

DONOTADMITTOLJABILiTY. DONOT

INFERORPROMISETOPAY.

Useonlytheacceptablestatement:"Theacci­

dentisunderinvestigation,"NOTHINGMOREi

4.INVESTIGATION:Cooperatewithyourinsurancecompanyrepresentative.Letthispersonmakeanyandallconclusiveinvestigations.

5.WITNESSES:Securenames,addressesandphone

numbers(homeandwork)ofwitnessesassoonas

possibleaftertheaccident.NOTHINGMORE!

6.PHOTOS:Takephotosofallaccidentscenesassoonaspossible.

WAIVERRELEASE:(Ifrequired)Ifinsuredpersonwasinrestrictedarea,locate signedWaiverandReleaseimmediatelyandstoreinsafeplace.Sendtotheinsurancecompanyonlybyrequestandbyregisteredmail.RetainphotocopyofWaiverandReleaseforyourfile.

LOCALAUTHORITIES:Iftheincidentisinvestigat­edbylocalauthorities,identifytoK&K,I.e.police,fromwhattown,countyandstate.

CASEREPORTFORM:Completeallinformationrequiredandavailablewlthln24hours.Minimuminformationshouldincludefacilitynameandaddress,dateofaccident,victim'sname,addrBssandphonenumber;familynameandphonenumberiffatality;andthesignatureofthepersonthatcom­pleted form.

MailASAP-nothingcanbehandledbytheinsuringcompanywithoutthisinformation.

REMEMBER:NOTIFY K&KOFALLINCIDENTS,NOT.JUSTTHOSECATASTROPHICINNATURE.

PREPAREFOREMERGENCIES

1.HaveaqualifiedpersondesignatedtomakeALLpri­vate,publicormediastatements.Makeallpersonnelawarethatonlythedesignatedstatementpersoninquiresaboutaloss.

2.Makeaseparatequalifiedpersondesignated forallemergencymedical,fireandsecurityoperations.

3.Haveadequatepersonnelonsite:security,medical,andfire protectionservicesandequipment."Adequate"meansproperandprudentforyourantic­ipatedattendanceandeventactivity.

4.Havebackuppersonnelandequipment,includingbackuppowersources,inplacetomaintaineventintegrity.

. 5. Haveawrittencrisismanagementplanthataddressesall"worstscenario"situations,includingevacuation.

6.Trainandpracticeallemergencyprocedures.

7.Ifpolicywordingrequiresit,haveadequatesuppliesofWaiverandReleaseforms.Haveadequateaccidentreportingformsonsite.ThosewhomustsignaWaiverandReleaseformarethosepersonspracticingand/orparticipatinginanyathletlceventsponsoredbyyou,aswellasanyoneenteringarestrictedarea,whichisgenerallydefinedasanyareawhereadmittancetothegeneralpublicisprohibtted.

8.HavethenameandnumberofyourInsuranceContactpostedprominently..Incaseofamajorspecta1orlossorfatality,K&K's24-hournumberis260-45S-5000.Haveonepersonresponsibleforthiscall.CallK&Kdirect; donotrelyonaBroker,etc.torelaythecall.

SD-10 (1010) 1/03