For Tackle, Flag Football And

DAY CAMPS OFFICIAL
INSURANCE PLANS

For Tackle, Flag Football and

Cheerleading Day Camp Activities

For Policy Year beginning August 1, 2017and ending July31, 2018

Available Only For Pop Warner Football & Cheer Day Camp Programs

Pop Warner Little Scholars, Inc.

586 Middletown Boulevard, Suite C-100

Langhorne, PA 19047

Telephone: (215) 752-2691

Facsimile: (215) 752-2879

IMPORTANT NOTE: If an individual Pop Warner Football League (and/or Association) does not select the Pop Warner Day Camp Insurance Program, that League (and/or Association) is responsible for providing Pop Warner Little Scholars, Inc. a certificate of insurance showing limits equal to or greater than the limits provided under the Pop Warner Day Camp Insurance Program.

****An approved Event Request Form must be sent with this Application****

Please refer to Page 9

ENROLLMENT FORM FOR POP WARNER DAY CAMPS INSURANCE PROGRAM

IMPORTANT NOTICE: When any type of insurance is purchased by a LEAGUE on its own behalf and/or on behalf of its member associations (teams), this form must accompany the LEAGUE Annual Registration Form or the LEAGUE must already be registered with Pop Warner Headquarters for the season. If the Applicant is an association acting on its own behalf (i.e. not as part of an LEAGUE application), the association must make sure its LEAGUE is already registered. If the LEAGUE has not yet registered, processing of the association’s enrollment will be held up until the LEAGUE registers.

SECTION I IDENTIFICATION

Name of League:

Association’s Full Name:

Insurance Coordinator’s Name:

E-mail:

Insurance Coordinator’s Signature:

Street Address:

City/State/Zip Code:

Coordinator’s Telephone Numbers: Daytime: ( )

Evening: ( )

Best Time: ( )

FAX Number: ( ) ______

If Pop Warner Insurance Program for Day Camps is not selected, the LEAGUE is responsible for providing Pop Warner Little Scholars Inc. a certificate of insurance showing limits equal to or greater than the limits provided under Pop Warner Insurance Program for Day Camps.

SECTION II - POP-WARNER FOOTBALL AND CHEER DAY CAMPS (Excess Accident Medical Expense & General Liability Coverage)

Coverage Period: 08/01/17 to 07/31/18

COVERAGE / # of Participants / Combined Rate / # of Days / TOTAL
Combined Excess Accident Medical Expense & General Liability / X $1.82 X / =

Combined Rate of $1.82 includes $0.88 for Excess Medical, $0.91 for Liability and $0.03 for S/L Tax.

GENERAL INFORMATION – ALL INSURANCE PLANS

Dates of Coverage: Coverage for all insurance plans begins on August 1, 2017 or the day after the postmark date of the enrollment form, whichever is later. All insurance coverage ends July 31, 2018.

Refund Policy: Only refund request written on the official stationary of the applicant, and received at Pop Warner headquarters on or before July 31, 2018 will be honored. The refund policy only applies to unformed camps and does not apply to individual drops.

Associations: If an association purchases Excess Accident Medical and Liability Insurance on its own (i.e. not as a part of a League), its League must already be registered for the 2018 season.

Processing of Insurance Plan:The Excess Accident Medical Expense is underwritten by The Hartford; Liability, and Inland Marine/Equipment Floater Insurance Plans are underwritten byNational Casualty Company. Claims are administered by K&K Insurance Group, Inc.

EXCESS ACCIDENT MEDICAL EXPENSE INSURANCE

INSURED PERSON means any person who is a registered participant in a(n) camp/clinic sponsored by the

Policyholder.

COVERED ACTIVITIES means

This policy covers each Insured Person during the policy period while he or she is:

(a) participating in football, flag football and/or cheer camp/clinic activities:

(1) sponsored by the Policyholder; and

(2) on the premises designated and supervised by the Policyholder; or

(b) traveling with a group in connection with the activities under the direct supervision of the Policyholder.

EXCLUSIONS

The Policy does not cover loss resulting from or for:

1. intentionally self-inflicted Injury, suicide, or attempted suicide, whether sane or insane;

2. war or act of war, whether declared or undeclared;

3. Injury sustained while in the armed forces (land, water or air) of any country or international authority;

4. Injury sustained while in or on, boarding or alighting from, being struck or run down by, any aircraft except

as an airline passenger on an aircraft: (a) operated by a passenger airline on a regularly scheduled trip over its

established route or that is chartered by that airline; or (b) any transport type aircraft operated by the Military

Airlift Command (MAC) of the United States or any national government recognized by the United States;

5. repair, replacement, examination for prescriptions, or fitting of: (a) eyeglasses; (b) contact lenses; or (c)

hearing aids;

6. dental work or treatment on natural teeth which is not necessary for the repair or relief of Injury;

7. repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other

artificial dental restoration;

8. repair or replacement of artificial limbs or orthopedic braces;

9. Injury for which the Insured Person is eligible to receive Workers’ Compensation benefits or similar benefits,

regardless of whether he or she has applied for the benefits;

10. Injury sustained while the Insured Person is voluntarily taking drugs which federal law prohibits dispensing

without a prescription, including sedatives, narcotics, barbiturates, amphetamines or hallucinogens, unless

the drug is taken as prescribed or administered by a licensed Physician;

11. Injury sustained by an Insured Person during or as a result of his or her commission of a felony or while

incarcerated for a felony, except that this exclusion will not be applicable upon acquittal or dismissal of the

felony charges;

12. Injury sustained as a result of the Insured Person’s being legally intoxicated from the use of alcohol while

operating a motor vehicle;

13. Expenses incurred for services, treatment, supplies or facilities rendered by: (a) the Policyholder’s health

service or infirmary; or (b) any Physician or nurse employed or retained by the Policyholder;

14. Expenses covered under any Motor Vehicle Financial Responsibility Law, automobile reparations insurance

(no-fault) or automobile insurance medical payments benefit;

ACCIDENT MEDICAL EXPENSE BENEFIT

We will pay the Reasonable Expenses incurred by an Insured Person, in excess of the Deductible Amount, for

Medical Care due to:

(a) Injury, if the first expense is incurred within 26 weeks after the accident; and

(b) the expense is incurred within 2 years after the accident.

We will not pay:

(a) more than the Maximum Benefit for all expenses incurred as the result of any one accident; or

(b) for expenses incurred more than 2 years after the accident.

We will not pay:

(a) more than the Maximum Dental Limit for all expenses incurred for dental treatment, services and

supplies; or

(b) more than the Maximum Benefit for all Medical Care and dental treatment, services and supplies,

as the result of any one accident.

The Deductible Amount will be applied separately to each accident. The Deductible Amount, Maximum Dental

Limit and Maximum Benefit are shown in the Schedule.

Medical Care, for the purpose of this benefit, means necessary:

(a) medical or surgical treatment, services and supplies; and

(b) Hospital, nursing and ambulance services,prescribed by a Physician for the sole purpose of treating the Injury.

EXCESS COVERAGE PROVISION:

The amount otherwise payable under the Accident Medical Expense Benefit will be reduced by the total amount

of medical care benefits provided by any other Plan. The amount of benefits provided by other Plans:

(a) will be determined without reference to any:

(1) coordination of benefits provision;

(2) non-duplication of benefits provisions; or

(3) other similar provisions,

(b) will include any amount to which the Insured Person is entitled, regardless of whether claim is madefor the benefits; and

Plan means:

(a) group insurance;

(b) group Hospital, medical service or pre-payment plan;

(d) governmental programs or coverage required or provided by any statute; or

(e) Workers’ Compensation or similar law.

Since the Policy provides only an EXCESS MEDICAL EXPENSE BENEFIT, THE INSURED MUST FIRST FILE THE CLAIM WITH THE INSURED'S EXISTING INSURANCE PLAN (including major medical) before submitting a claim. If the insured has no other insurance in force, the Policy will pay theReasonable Expensesincurred by an Insured Person for Medical Care.

BENEFITS AND AMOUNTS EXCESS COVERAGE APPLIES:

Accidental Death Benefit Principal Sum:$10,000.00

Accidental Dismemberment Benefit Principal Sum: $10,000.00

Accident Medical Expense Benefit Maximum Benefit:$100,000.00

Deductible Amount: $0.00

Maximum Dental Limit: $250.00

ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) BENEFIT:

If the Insured Person’s Injury results in any of the losses listed in the table below within 180 days after the date of the accident, except for loss of life, we will pay the sum shown opposite the loss. We will not pay more than the Principal Sum shown for each Insured Person for all losses due to the same accident. The Principal Sum amount is shown in the Schedule.

Loss of Life / Principal Sum / Speech and Hearing in Both Ears / Principal Sum
Both Hands or Both Feet / Principal Sum / One Hand or One Foot / One-half the Principal Sum
Sight of Both Eyes / Principal Sum / The Sight of One Eye / One-half the Principal Sum
One Hand and One Foot / Principal Sum / Speech or Hearing in Both Ears / One-half the Principal Sum
One Hand and the Sight of One Eye / Principal Sum / Thumb and Index Finger of Same Hand / One-quarter the Principal Sum
One Foot and the Sight of One Eye / Principal Sum

Loss means, with respect to:

(a) hand and feet, actual severance through or above wrist or ankle joints;

(b) sight, speech and hearing, entire and irrecoverable loss thereof;

If more than one Loss is sustained by an Insured as a result of the same accident, only one amount, the largest, will be paid.

Definitions:

Hospital means an institution which:

(a) operates pursuant to law;

(b) primarily and continuously provides medical care and treatment of sick and injured persons on an inpatient basis;

(c) operates facilities for medical and surgical diagnosis and treatment by or under the supervision of a staff of legally qualified physicians; and

(d) provides 24 hour a day nursing service by or under the supervision of registered graduate nurses (R.N.).

Hospital does not mean any institution or part thereof which is used primarily as:

(a) a nursing home, convalescent home or skilled nursing facility;

(b) an alcohol or drug treatment facility; or

Injury means bodily injury of an Insured Person that results directly and independently of all other causes from

an accident which occurs while he or she is participating in a Covered Activity.

Loss resulting from sickness or disease, except a pus-forming infection that occurs through an accidental wound,

is not considered as resulting from Injury.

Insured Person is defined in the Schedule.

Physician means a legally qualified physician or surgeon, other than the Insured Person or a physician or surgeon

who is related to the Insured Person by blood or marriage.

Reasonable Expenses means fees and prices which do not exceed those generally charged for similar Medical

Care in the local area where received by the Insured Person. An expense is considered to be incurred on the date

the Medical Care is rendered.

We, us or our means the Hartford Life and Accident Insurance Company.

Date(s) of Coverage: - Your insurance will become effective August 1, 2017, or the date on which your Enrollment Form and premium payment are received, whichever is later, and continues until the completion of the playing season as outlined above under "Covered Activities" but in no event later than July31, 2018.

The information provided is only a brief description of the coverage(s) available provided for illustrative purposes only and is not an insurance contract. You must refer to the policy on file with the policy holder for specific limits, conditions, and exclusions. If there is any conflict between the contents of this document and the Policy, the Policy will govern in call cases.

EXCESS ACCIDENT MEDICAL EXPENSE INSURANCECLAIM PROCEDURES

When there is an injury, the Insured Person should then request a claim form from K&K Insurance Group, Inc. by calling 1-800-237-2917or a claim form can be obtained from the website.
The Insured Person should file all their medical bills with theirPRIMARY health insurance company or family medical insurance provider. The Insured Person should be sure to follow the guidelines of theirPRIMARY health coverage plan (i.e., HMO, PPO, POS, etc.).
Submit your completed Accident & Health claim form, itemized bills and Explanation of Benefits from theirPRIMARY health insurance company to:

K&K Insurance Group, Inc.

Claims Department

P.O. Box2338

Fort Wayne, Indiana 46801-2338

Fax: 312-381-9077

Email:

If there are any questions regarding a claim, call: K&K Insurance Group, Inc. by calling 1-800-237-2917.

LIABILITY INSURANCECLAIM PROCEDURES

When there is an injury, the Policyholder should complete an incident report claim form which can be obtained from Pop Warner by contacting Beth Dietz at 215-752-2691, ext. 122.
Mail, fax or email your completed incident report claim form to:

K&K Insurance Group, Inc.

Claims Department

P.O. Box 2338

Fort Wayne, Indiana 46801-2338

Fax: 312-381-9079

Email:

Phone: 1-800-237-2917

Fax: 312-381-9079

If there are any questions regarding a claim once it has been reported, call K&K’s Toll Free number:1-800-237-2917.

PLEASE NOTE THE NEED TO INCLUDE THE INTEREST/RELATIONSHIP OF EACH ADDITIONAL INSURED

SECTION III – ADDITIONAL INSURED CERTIFICATE LIST

Information for additional insured certificate(s)

Type or print the complete names and address of each qualified additional insured. Attach extra sheets as necessary.

Name of Requesting Association / Name of Requesting Association
Name of Certificate Holder / Name of Certificate Holder
Address of Certificate Holder / Address of Certificate Holder
City, State & Zip Code / City, State & Zip Code
Interest/Relationship of Additional Insured
Name of Requesting Association / Name of Requesting Association
Name of Certificate Holder / Name of Certificate Holder
Address of Certificate Holder / Address of Certificate Holder
City, State & Zip Code / City, State & Zip Code
Interest/Relationship of Additional Insured
Name of Requesting Association / Name of Requesting Association
Name of Certificate Holder / Name of Certificate Holder
Address of Certificate Holder / Address of Certificate Holder
City, State & Zip Code / City, State & Zip Code
Interest/Relationship of Additional Insured

SECTION IV - 2017 EVENT REQUEST FORM

Please complete this request from for every event other than the League/Region/National Playoff/Competition System. Permission to participate in an event (i.e., tournament, bowl game, competition, parade, NFL half-time participation, etc.) is granted only if it is in writing, in advance and approved by the League, Region and Pop Warner National Office.

An event must follow Pop Warner guidelines as listed:

A Pop Warner League may apply for its association team(s)/squad(s) to participate in an event sponsored by a Pop Warner organization, a group of Pop Warner Leagues or a Pop Warner Bowl/Festival, which occurs during the accepted Pop Warner season and follows all Pop Warner safety guidelines.

A Pop Warner League may apply for an event sponsored by a Non-Pop Warner organization if it follows all Pop Warner safety rules and occurs during the accepted Pop Warner season. In the case of competition for Pop Warner Football teams, the Pop Warner Age/Weight Schematic and all rules in the Official Pop Warner Rulebook must be followed.

The Event Host is:Pop Warner AffiliatedNon-Pop Warner Affiliated(Circle One)

Event Name:______

Event Sponsor:______

Event Date:______

Event Location:______

Description of Event and Activities (i.e. Bowl Game, Parade, Competition, Half-Time Performance, etc.)

______

Please Circle:

Teams/Squads:Football Divisions:TM MM JP PW JM M JB B U

Cheer Divisions:TM MM JP PW JM M JB B U

Dance Division:TM MM JP PW JM M JB B U

Participating League(s)______

Association(s)______

Is the event open to the entire League? If no,

Pleaseexplain:______

Does the event provide as part of its services an accident insurance plan?

Provide Details:______

______

Person Submitting FormTitleEmail AddressPhone Number

______
League Signature

______

Region Signature

Please do not send to the following address unless the League and Region has approved.

Camp dates need to be shown on the application so they can be shown on the certificate.

Refund will be processed for unformed camps. No refunds for individual drops. Only refund request written on the official stationary of the applicant, and received at Pop Warner headquarters on or before July 31, 2017. will be honored.

*** PLEASE ATTACH COMPLETE ROSTER ***

Camps without rosters will not be accepted

Attach check payable to K&K INSURANCE GROUP, INC. in the amount of the Total Payment Due. Send check and application for 2017 POP WARNER DAY CAMPS INSURANCE PROGRAM to:

POP WARNER LITTLE SCHOLARS, INC.

586 Middletown Boulevard, Suite C-100

Langhorne, PA 19047