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PROOF OF INSURANCE (2022) CLOSEDCERTIFICATE OF LIABILA TY INSURANCE 4/t2 I'HiS CETT—HCATE`, IS ISS(JED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RlGiHTS UPON -11HE CERTIFh.-,Al-F HOLDER TI70S CEI:Z11RCAFE DOES NOT AFF�RMATIV� - "LY OR NEGAT]VELY AMEND EXTEND OR ALTER 7HE COVERAGE AFFORDED BY THE POLIC"JES BP 01VIV, THIS CERTIFICAll OF INSURANCE DOES N01' CONSTGWTE A CONTRACT BETWEEN THE ISSUING 4NSIJRER(S). AUTHORIZED REPRESEN-FATrVE OR PRODUCER AND I'HE CERTIFuCA'l E H011-DER IMPOR]ANF If the ceitificate holder is wi ADDITIONAL INSURED, the pohcy(ies) must b� endomed If SUBROGATIOIN IS WAIVED subject to the Nernis and conditions of the policy, certwn poiicres may equire an endorsemient A staterrent on this ceulificate does noti;amfer rights to the cur lificate hoidein lieu; osuch t:,-ndorsement(s). Frazier ­Insura�ncrApnq, Inc,, Frazier Insurance Agency, Inc. R. Box 1250 Midlothian, VA 23113-1250 IN4(, 00 RN'J "Ic United States Fire lnsuranc�-r Company 21113 WTMRD Sports & Rec?"ation PnwCRmsAssn Rtsk I'Amimplinmil hr, El Segundo Inline Hockey Association PO Box 3061 El Segundo, CA 90245 I FT r i F - - COVERAC.ES CERTIFICA'm NUMBER': F", 1:V I S ON N U Me E R IS R) (,FRrjFy THAT fHE POLNCIFS ()F INS(JRANCE USIED BELOW HAVE BEEN dSSUED TO lffl, NSURIED NAi ABOVf- FOR TIAF POLICY PERIOD NOCATED NOTWITHSTANDING ANY REQUIlREMEW 'IERNI OR G()NJ,'lM0l`4 OF ANY (,''WJTRACI OR 0IFIER DOCUMENT VVIIii-I RESPECT 10MUCH THiS M10' RE ISSUFAD OR MAY PFRIAIN'NICE, iNSURANCE AFFORDED BY rFW, POLICIES DESCRIBED HEREW IS SUBJECT TO ALL 1HE lFWAS EKLUSUlS, AND (-,f,,)NDHF10NS OF SUCH POLUES LiMiTS SHCYVVN PAM HiAV[� 1.,a+EFN R[.C1UC',CD BY PAICiCLAPOS, N',MiAN(A' I YP�� 01 FM Icy i NS %04 "i 11 C;i W F1,11,ifll ITY \-1 iNGLUDLS A'T+fl-L I G PAP, icir'ANTS (5LIN kM,�MJ �A Y L � Nfl AJPP� [J,, PIR AU I WAULM 1JABli 1 Y ANI HOJM-D "C"WNIND 13FNEHM AG'CHECA I E T, 2,00U00 00 - --- — --------- PR(�[mjcic'� CXYAIVOPAXi t 2,000,1 0710l/2021 01/01/2022 NHAS(A,�Al &ADVNJUNY $ 1,000.000 00 SRPGAPML-101-07'20 P ACH KGOM171"'IM: $ 1,000 00000 12 01 AM --f-Mr UVAA(A'Ooy One $ 300,00000 NAI: D 5 000.00 GLAil" ('.ERTil`-ICA � E HOLDER El Segundo li Hockey Assobation PO Box 3061 El Segu�ndo, CA 90245 B0DILY Eilij(Ny IN,, $ BON Y NARy We, "','ldcqti 'I Ph ",T FACH OG'CUPIREINCr" S 2 CANK.',ELLATIONS SHOULD ANY OF THE ABOVFF DESCRIBED POIJUES BE. CANCELLED Br""FORE: THE EXPIRATON 0A'FE "FHEREOF, NOTICE V11L. BE DEUVERED IN ACCORDANCE Will -I THE POLICY PROV10ONS AUTi iORIZED 17TPRESFN WNE , John JV T'rar ier ry 1988-2010 ACIORD CORPORATION, Ail rights reSf�I-Ved AGORD 25 (2010/05Th. mnmr, t'unH ir'nr' 4<711r i)A I I t4W�Afl)��),VYYY CERTIFICATE OFLIABILITY INSURANCE 611 /2021 Tt1IS--aF—\1TrI 6 6SPOED AS A MATTER OF INFOPMATtON ONLY AND CONFERS NO RIGHTS UP(ON -rHIE GEP1TiFK,'AT'E HOLDER 'THS (.',1EP,1TIFICATE DOES 1140T AFFRIMATIVELY OR NEGATIVELY AMEND EXTEND CIR ALTER FHE (,'OVERAGE AFFORDED H,.,Y TiE F,10U('.JES BELOW. THIS C'E- ' RTIFICIIAFE� OF WSURAN(X DOES NOI1 GONSTkTUTE A CONTRACT BETWEEN THE tlSSIJING INSURER(S) ALITHOmZu-) f'-TE PRI--`8 E NTA TVE OR PROOLKER, AND -1 HE CATE HOLDER. IMPOR TAN ff 0he certificate hcldens an ADDII D IONAL INSURED, Nhe prokyf i,!smust en c,.fosf.,-.d. ff SUE31ROC',Al VON US,, WAIVED sutjject to ffie te",ns and con6fions of the pcflicy, cert&n pclNces may requ6e '.)n endorsemerit A SLN teMent (,m ths cerfificate does not confer rights to the u,mbfic,ate holder m heu of such endcIs�.-,,m i t CON �,flu' PJAMIL Fraziel,r insurance AgencInc y, I I'k, j I", I ( Frazier Insurance Agency, Inc. P.0 Box 1250 Udloftari, VA 231,13-1250 El Segundo Inline Hiockey Assobation PO Box 3,061 El Segundo, CA 90245 NYSURERA, United States Fire Insurance Company 21113 N5I)Wrw INSURERF I fl:UrH COVERAGES CERHFK",AQ"E NUT BER� REVISION NUMBER - hfiS 1S' 10 CERTIFY THAN' THE POLICIEI,� OF INSURANCE I �,STEI') BE ' I 010i HAVE' 8EI' " N Ta'THE MSIJF,�ED NAMED ABOVE FOR J"orrIE PIDUCY PEMOD N[)I(.',,'kTErD NOTWI F) d STAN DING ANY REOUIREMENT fFFP4 OP CONDPIGN OF ANY C(IN-FR/;C;"r OR OTHER DOCUMENF WITH RFSPECT IoWmc,h�i ;mS CERTIFICAFMAY [3[,, ISSUED OR MAY PERNON, THE , r INSURANCE, A1Ir'0R[Np(-D BY lffl,', POUG'IES DESCRIBED HFRE1N 6S aDBJEC,] 10 ALL THL. IERMS F, XCLUSD0116 AND CONDITIONS C)F: SUCH POLICES LIMITS SHOWN MAY HAVE BEEN REDUCTD BY PAR) GLABW; ,tR 1, 0 'I 101COFINSURANU n,I)POLK, y NUMU R, VIA( MWID),v'(, GN,ILRAt m ANI 1-Pe (TNr4W AG(,RFGATF s 2,0010,000,00 X, E 2,N7CDED 0E1tD. rD0 pp (Jjdlw,rA11MF 07�01/2021 07�01/2022 rf-RSONN A AIN INJI-JRY S 1,000.000= SRPGAPML-101-0720 A 12 Ot AM: [ ACH OCCURRENCE $ 1 000 000 00 INCLUDE!,,' ATHLETIC PARTICHIANTS 300,000`00 ,,'VN 1. /V`,G- 0 WP�qq-`J J'[, I'f N&D FXP Anv o, 5.000.00 gr,----- )4WUMUii9.t' L1AWU1Y ardv 7 RC)I)H,Y INJURY ;Pr,, pergon, H, Al L '. �YA RON Y INJURY (I'm /6 ��IRDPE PTYDA MACE Ei 4 -` 71,11L,I A("H ()f'(JjRRF1W1, $ XCF: SS fAR M", AG(; R 1, (' A l4, S .. .... ------ W o;C101"11 ONOa 0I11 HUCS (PilxAhAC(PM iNmwe,,pace qwfed) p(JUCY DEDUCTO E $000 PM EACH BODILY NjURY OP PROPFRTY OANIAGE CAMM Cerfificate Holder is An Additional Imired, But Only As Respects The Operations Of The Named Insured CFRTIFtCATFHOLDER CANCEUI-A 710N The City of El Segundo, its officers, officials, employees, agents and volunteers 350 Main Street El Segundo, CA 90245 SHWLD ANY OF 1HE ABOVE DESCRIBED POLUES BE CANCELLED BEFORE THE EXPIRKnON DATE "THEREOF. NiOT r KF WKA. BE', DELIVERED 9N ACCORDANC,EWITIH THE POLICY PROVIStONS AJ.)THORIZED REPRFSENIATIVF j(,ihn iW Trazi?r I qr.DP-20 10 ACORO CORPORIA"flON AH rights meserved A(,'ORD �',5 (2010/05) n-, rnn, V,c: r,A UNITED STATES FIRE INSURANCE COMPANY Administrative Offices: 5 Christopher Way • 3,d Floor • Eatontown, NJ 07724 BLANKET BENEFITS FOR ACCIDENTS ONLY CERTIFICATE OF COVERAGE This Certificate contains the terms under which the United States Fire Insurance Company agrees to insure certain persons and pay benefits. This Certificate is a part of, and is governed by, a Group Policy that has been issued in the state of ILLINOIS and shall be governed by its laws. Coverage under this Certificate is provided in consideration of payment of the initial premium, continued payment of premiums when due, and completion of an Application. This Certificate is a part of, and is governed by, a Group Policy. The Group Policy has been issued to, and is the contract between, the Group Policyholder and The United States Fire Insurance Company. The Group Policy is held by the Group Policyholder and may be inspected upon request at any reasonable time. The name of the Group Policyholder is shown in the Schedule. This Certificate has been issued to you, the Certificateholder, as a Participant under the Group Policy, in accordance with the terms, conditions, and limitations of the Group Policy. 10 DAY RIGHT TO RETURN THIS CERTIFICATE If for any reason, you are not satisfied with this Certificate, you may return it to us within 10-days after receiving it. Upon its return, we will refund any premium paid and this Certificate will be deemed void, just as though it had never been issued. THIS IS ACCIDENT ONLY COVERAGE. READ IT CAREFULLY. BENEFITS ARE NOT PAYABLE FOR LOSS DUE TO SICKNESS. THIS CERTIFICATE PAYS BENEFITS FOR SPECIFIC LOSSES FROM ACCIDENTS ONLY. THIS CERTIFICATE IS NOT RENEWABLE. Signed for The United States Fire Insurance Company By: Signature Signature 46, I ` ^� L � -- ""g Douglas M. Libby James Kraus Chairman and CEO Secretary GAC26932 TABLE OF CONTENTS The following provisions appear within this Certificate in the following order: Schedule of Benefits Definitions Scope of Coverage Description of Hazards Description of Benefits Exclusions Additional Exclusions Limitations Premium Provisions General Provisions Claim Provisions GAC26932 SCHEDULE OF BENEFITS COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER: AH-GA26932-002 ISSUED TO GROUP POLICYHOLDER: The Group and Blanket Accident & Health Insurance Trust CERTIFICATEHOLDER: El Segundo Inline Hockey Association CERTIFICATE NUMBER: US1334531 CERTIFICATE EFFECTIVE DATE: 07/01/2021 12:01 AM CERTIFICATE EXPIRATION DATE: 07/01/2022 12:01 AM BENEFIT PERIOD: Provided treatment begins within 90 days from the date of Injury, Benefits are payable for 12 months from the date of an Injury. The Injury must occur after the Effective Date and prior to the Expiration Date and care must be Medically Necessary. PREMIUM: $240.00 DEDUCTIBLE AMOUNT: $100.00 COINSURANCE PERCENTAGE: 100% of Usual, Reasonable & Customary Charges, URC MAXIMUM BENEFIT AMOUNT: $10,000.00 ELIGIBLE PERSONS: All Players, Coaches, Managers, Volunteers of the Policyholder's Programs SPECIFIED ACTIVITY: In Line Hockey MEDICAL EXPENSE BENEFIT Hospital Room & Board Daily Maximum Benefit Amount: URC Intensive Care Room & Board Daily Maximum Benefit: URC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre -Admission Testing Benefit Amount: URC Outpatient Hospital Emergency Room Treatment Maximum Benefit Amount: URC Surgical Benefits Primary Surgeons Maximum Benefit Amount: URC Assistant Surgeon, Second Surgical Opinion, Consultation Maximum Benefit: URC Anesthesia Maximum Benefit: URC Surgical Facility Maximum Benefit per Operating Session: URC Doctor's Visits In -Hospital Maximum Benefit: URC Office Visits Maximum Benefit: URC Maximum for All In -Hospital and Office Doctor's Visits: URC X-ray and Laboratory Maximum Benefit Amount: URC Nursing Maximum Benefit Amount: URC Physiotherapy Benefit Maximum Benefit Amount (Hospital Inpatient): URC Maximum Benefit Amount (Outpatient): URC Maximum for All Physiotherapy Combined (Inpatient & Outpatient): URC GAC26932 Ambulance Maximum Benefit Amount: URC Medical Equipment Rental Charges Maximum Benefit Amount: URC Medical Services and Supplies Maximum Benefit Amount (Blood, Blood Transfusions, Oxygen): URC Dental Treatment For Injury Only Maximum Benefit Amount: URC OUT -PATIENT PRESCRIPTION DRUG BENEFIT Maximum Benefit Amount: URC ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT, SPEECH, OR HEARING Principal Sum: $10,000.00 GAC26932 DEFINITIONS The terms shown below shall have the meaning given in this section whenever they appear in this Certificate. Additional terms may be defined within the provision to which they apply. "Accident" means a sudden, unforeseeable external event which: (1) Causes Injury to one or more Covered Persons; and (2) Occurs while coverage is in effect for the Covered Person. "Benefit Period" means the period of time from the date of Injury, as shown in the Schedule of Benefits "Covered Person" means a person eligible for coverage as identified in the Application for whom proper premium payment has been made, and who is therefore insured under this Certificate. "Deductible" means the amount of Eligible Expenses which must be paid by the Covered Person before benefits are payable under this Certificate. It applies separately to each Covered Person. "Doctor" means a licensed practitioner of the healing arts acting within the scope of his license. Doctor does not include: (1) The Covered Person; (2) The Covered Person's spouse, child, parent, brother, or sister; or (3) A person living with a Covered Person. "Eligible Expenses" means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while this Certificate is in force. "He", "his" and "him" includes "she", "her" and "hers." "Health Care Plan" means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under: (1) Group or blanket insurance, whether on an insured or self -funded basis; (2) Hospital or medical service organizations on a group basis; (3) Health Maintenance Organizations on a group basis. (4) Group labor management plans; (5) Employee benefit organization plan; (6) Professional association plans on a group basis; or (7) Any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended. "Hospital" means an institution which: (1) Is operated pursuant to law; (2) Is primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis; (3) Is under the supervision of a staff of doctors; (4) Provides 24-hour nursing service by or under the supervision of a graduate registered nurse, (R.N.); (5) Has medical, diagnostic and treatment facilities, with major surgical facilities; (a) On its premises; or (b) Available to it on a prearranged basis; and (6) Charges for its services. "Hospital" does not include: (1) A clinic or facility for: (a) Convalescent, custodial, educational or nursing care; (b) The aged, drug addicts or alcoholics; or (c) Rehabilitation; or (2) A military or veterans hospital or a hospital contracted for or operated by a national government or its agency unless: GAC26932 (a) The services are rendered on an emergency basis; and (b) A legal liability exists for the charges made to the individual for the services given in the absence of insurance. "Hospital Stay" means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital. "Injury" means bodily harm which results, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. "Medically Necessary" or "Medical Necessity" means the service or supply is: (1) Prescribed by a Doctor for the treatment of the Injury; and (2) Appropriate, according to conventional medical practice for the Injury in the locality in which the service or supply is given. "Nurse" means either a professional, licensed, graduate registered nurse (R.N.) or a professional, licensed practical nurse (L.P.N.). "School" means the participating School or School District where the Covered Person is enrolled or employed. The School must be a duly accredited (state certified or accredited) primary, elementary, secondary, or collegiate School. "Sickness" means illness or disease which begins or for which an expense was first incurred while coverage is in force under this Certificate for the Covered Person. Sickness includes complications of pregnancy. All related conditions and recurring symptoms of sickness to the same person will be considered one sickness. "Student Infirmary" means an on campus facility which: (1) Provides medical care and treatment to sick and injured students and faculty; (2) Is under the supervision of a Doctor; (3) Provides nursing services; and (4) Charges for its services. "Student Infirmary" does not include: (1) Medical, diagnostic or treatment facilities with major surgical facilities: (a) On its premises; or (b) Available to it on a prearranged basis; or (2)ln-patient care. (No benefits are payable for services, supplies, or treatment in a Student Infirmary. This definition is applicable only to its reference in the provision titled Additional Exclusions.) "Supervised or Sponsored Activity" means a Certificateholder or School authorized function: (1) In which the Covered Person participates; (2) Which is organized by or under its auspices; which is within the scope of customary activities for such entity and is shown on the Schedule of Benefits. "Usual, Reasonable and Customary means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a) Usually charged by the provider for the service or supply given; and (b) The average charged for the service or supply in the locality in which the service or supply is received; or (2) With respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition. SCOPE OF COVERAGE We will provide the benefits described in this Certificate to all Covered Persons who suffer a covered loss which: (1) Is within the scope of the DESCRIPTION OF BENEFITS PROVISIONS and results, directly and independently of disease or bodily infirmity, from an Injury which is suffered in an Accident; (2) Occurs while the person is a Covered Person under this Certificate; and GAC26932 (3) Is within the scope of the risks set forth in the DESCRIPTION OF HAZARDS provisions. Full Excess Medical Expense: If an Injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, we will pay the Eligible Expenses incurred, subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. The Covered Person must be under the care of a Doctor when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury: (1) While the person is insured under this Certificate; or (2) During the Benefit Period stated on the SCHEDULE OF BENEFITS. The first Expense must be incurred within the time frame shown on the SCHEDULE OF BENEFITS. The total of all medical benefits payable under this Certificate is shown on the SCHEDULE OF BENEFITS: and (1) Subject to the specific maximums shown on the SCHEDULE OF BENEFITS; and (2) Subject to compliance with the requirement, set forth in the Limitations section of this Certificate. Non -Duplication of Benefits Provision: This provision applies if a Covered Person: (1) Is covered by any other blanket or group health care plan; and (2) Would, as a result, receive total medical expense or service benefits in excess of the expenses actually incurred. In this case, the medical expense benefits we will pay under this Certificate will be reduced by such excess. This provision does not apply if we would be primary under any coordination of benefit guidelines contained in the other health care plans. PROVISIONS CONCERNING COVERED PERSONS Eligibility: Persons eligible to be insured under this Certificate are those persons described as an ELIGIBLE CLASS on the Application who have completed any applicable Service Waiting Period. This includes anyone who may become eligible while this Certificate is in force. Effective Dates: A Covered Person will become an insured under this Certificate, provided proper premium payment is made, on the latest of: (1) The Effective Date of this Certificate; or (2) The day he becomes eligible according to the referenced date shown in the Application. Termination: Insurance for a Covered Person will end on the earliest of: (1) The date he is no longer in an Eligible Class. (2) The date he reports for active duty in any Armed Forces, according to the referenced date shown in the Application. We will refund, upon receipt of proof of service, any premium paid, calculated from the date active duty begins until the earlier of: (a) The date the premium is fully earned; or (b) The Expiration Date of this Certificate. This does not include Reserve or National Guard duty for training; (3) The end of the period for which the last premium contribution is made; or (4) The date the Group Policy is terminated. GAC26932 DESCRIPTION OF HAZARDS HAZARD: CERTIFICATE HOLDER FUNCTIONS Subject to all other provisions of this Certificate, coverage is provided for a Covered Person while he is: (1) Attending or participating in a Supervised or Sponsored Activity; or (2) Attending a Certificate holder function. The Covered Person must be: (1) On the premises of the Certificate holder: (a) During its normal hours; (b) During scheduled functions; or (c) During other periods if he is attending or participating in a Supervised or Sponsored Activity; (2) Not on Certificate holder premises and attending or participating in a Supervised or Sponsored Activity; (3) Traveling directly, without interruption: (a) Between his home and the Certificate holder's premises for participation in a Supervised or Sponsored Activity; (b) Between the site of the Supervised or Sponsored Activity and his home or the Certificate holder's premises. (c) In a vehicle which is: (i) Designated or furnished by the Certificate holder; (ii) Operated by a properly licensed adult driver; and (iii) Under the direct supervision of the Certificate holder; or (d) In a vehicle other than that described in (3)(c) when operated by a properly licensed driver. Travel time includes the time: (i) To or from home, the Certificate holder's address and the Supervised or Sponsored Activity; (ii) Before the appointed time; and (iii) After the Supervised or Sponsored Activity is completed. Unless otherwise stated, we will pay benefits for a covered loss, only once, even if coverage was provided under more than one Description of Hazards. DESCRIPTION OF BENEFITS BENEFIT A: BENEFITS FOR ACCIDENTAL DEATH, DISMEMBERMENT, LOSS OF SIGHT, OR SPEECH AND HEARING If, within 1-year from the date of an Accident covered by this Certificate, Injury from such Accident, results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table below. If the Covered Person sustains more than one such Loss as the result of one Accident, we will pay only one amount, the largest to which he is entitled. This amount will not exceed the Principal Sum which applies for the Covered Person. Loss Loss of Life Loss of Both Hands Loss of Both Feet Loss of Entire Sight of Both Eyes Loss of One Hand and One Foot Loss of One Hand and Entire Sight of One Eye Loss of One Foot and Entire Sight of One Eye Loss of Speech and Hearing (both ears) Loss of One Hand Loss of One Foot Percentage of Principal Sum 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% GAC26932 Loss of Entire Sight of One Eye Loss of Speech Loss of Hearing (both ears) Loss of Thumb and Index Finger of the Same Hand 50% 50% 50% 25% Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of speech means total, permanent and irrecoverable loss of audible communication. Loss of hearing means total and permanent loss of hearing in both ears which cannot be corrected by any means. Loss of a thumb and index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand). In California, loss of a thumb and index finger means loss by complete Severance of at least one whole phalanx of each. In South Carolina, the complete severance of four whole fingers from one hand equals the loss of one hand. "Severance" means the complete separation and dismemberment of the part from the body. BENEFIT - MEDICAL EXPENSE We will pay, Eligible Expenses for a Covered Person's Injury, subject to the Deductible Amount and Coinsurance Percentage, if any, shown in the Schedule of Benefits. Eligible Expenses are those incurred for: (1) Hospital Room and Board — charges for the most common semi -private daily room rate for each day of the Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for Hospital Room and Board. (2) Intensive Care Room and Board - charges for each day of Intensive Care Unit confinement, up to the Daily Maximum Benefit Amount shown in the Schedule of Benefits for the Intensive Care Room and Board benefit. This payment is in lieu of payment for the Hospital Room and Board charges for those days. (3) Hospital Miscellaneous - charges during a Hospital Stay, up to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for the Hospital Miscellaneous benefit. Miscellaneous charges do not include charges for telephone, radio or television, extra beds or cots, meals for guests, take home items, or other convenience items. (4) Outpatient Hospital Expenses - charges by a Hospital for: (a) Pre -admission testing (confinement must occur within 7 days of the testing); or (b) Emergency room treatment, up to the Maximum Benefit Amount per emergency shown in the Schedule of Benefits for the Outpatient Emergency Room Treatment benefit. (5) Surgical Benefits - charges for: (a) A Doctor, for primary performance of a surgical procedure, up to the Maximum Benefit Amount shown in the Schedule of Benefits per procedure. Two or more surgical procedures through the same incision will be considered as one procedure. However, we will pay up to 50% of the surgical procedure charge when more than one surgical procedure through different operating fields are performed during the same surgical session. (b) A Doctor, for: (i) assistant surgeon duties; (ii) a second surgical opinion; or (iii) consultation, up to the Maximum Benefit shown in the Schedule of Benefits for an Assistant Surgeon, Second Surgical Opinion, and Consultation. GAC26932 (c) Anesthesia and its administration, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Anesthesia benefit. (d) Use of surgical facilities, up to the Maximum Benefit Amount per operating session, as shown in the Schedule of Benefits for the Surgical Facility benefit. (6) Doctor's Visits - charges by a Doctor for other than pre- or post -operative care: (a) For in -Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Doctor's Visit — In -Hospital. (b) For office visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Doctor's Office Visits. Total visits per Injury will not exceed the combined Maximum shown in the Schedule of Benefits for All In - Hospital and Office Doctor's Visits. (7) X-Ray and Laboratory - charges for X-ray and laboratory tests, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the X-ray & Laboratory benefit. (8) Nursing Services - Charges for nursing services (other than routine Hospital care) by or under the supervision of a licensed graduate registered nurse, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Nursing benefit. (9) Physiotherapy - Charges for physiotherapy: (a) While Hospital confined, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Hospital Inpatient Physiotherapy benefit; (b) As an outpatient, up to the Maximum Benefit Amount shown on the Schedule of Benefits for the Outpatient Physiotherapy benefit. Physiotherapy includes: (a) Heat treatment; (b) Diathermy; (c) Microtherm; (d) Ultrasonic; (e) Adjustment; (f) Manipulation; (g) Massage therapy and (h) Acupuncture. Total treatment per Injury will not exceed the Maximum Benefit Amounts for Physiotherapy shown in the Schedule of Benefits. (10) Ambulance - from the place where the Injury occurred to the Hospital, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Ambulance benefit. (11) Medical Equipment Rental - charges for medical equipment for: (a) A wheelchair; (b) An iron lung; or (c) Other medical equipment for which prior approval by us has been given; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Equipment Rental benefit. (12) Medical Services and Supplies - Charges for medical services and supplies for: (a) Oxygen and its administration; (b) Blood and blood transfusions; up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Medical Service & Supply benefit. (13) Dental Treatment - Charges for dental treatment for Injury to a tooth which was sound and natural at the time of Injury, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Dental Treatment benefit. GAC26932 The amounts payable under this Medical Expense benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Certificate. BENEFIT - OUT -PATIENT PRESCRIPTION DRUG BENEFIT We will pay the Eligible Expenses, subject to the Deductible Amount and Coinsurance Percentage shown in the Schedule of Benefits, if any; for a Prescription Drug or medication when prescribed by a Doctor on an outpatient basis. Prescription Drug means a drug which: (1) Under Federal law may only be dispensed by written prescription; and (2) Is utilized for the specific purpose approved for general use by the Food and Drug Administration The Prescription Drug must be dispensed for the out -patient use by the Covered Person: (1) On or after the Covered Person's Effective Date; and (2) By a licensed pharmacy provider. Benefits are payable up to the Maximum Benefit Amount shown on the Schedule of Benefits. The amount payable under this benefit could be greatly reduced if the Covered Person does not comply with the requirements in the Limitations section of this Certificate. EXCLUSIONS Benefits will not be paid for a Covered Person's loss which: (1) Is caused by or results from the Covered Person's own: (a) Intentionally self-inflicted Injury, suicide or any attempt thereat. (In Missouri this applies only while sane.); (b) Voluntary self -administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor (Accidental ingestion of a poisonous substance is not excluded.); (c) Commission or attempt to commit a felony; (d) Participation in a riot or insurrection; (e) Driving under the influence of a controlled substance unless administered on the advice of a doctor; or (f) Driving while Intoxicated. "Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs; (2) Is caused by or results from: (a) Declared or undeclared war or act of war; (b) An Accident which occurs while the Covered Person is on active duty service in any Armed Forces. (Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days.); (c) Aviation, except as specifically provided in this Certificate; (d) Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. (e) Nuclear reaction or the release of nuclear energy. However, this exclusion will not apply if the loss is sustained within 180 days of the initial incident and: (i) The loss was caused by fire, heat, explosion or other physical trauma which was a result of the release of nuclear energy; and (ii) The Covered Person was within a 25-mile radius of the site of the release either: 1) At the time of the release; or 2) Within 24 hours of the start of the release. ADDITIONAL EXCLUSIONS Benefits will not be paid for: 1. Normal health checkups; GAC26932 2. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Certificate, and rendered within 6 months of the Accident; 3. Services or treatment rendered by a doctor, nurse or any other person who is: (a) Employed or retained by the Certificateholder; or (b) Who is the Covered Person or a member of his immediate family; 4. Charges which: (a) The Covered Person would not have to pay if he did not have insurance; or (b) Are in excess of Usual, Reasonable and Customary charges. 5. An Injury that is caused by flight in: (a) An aircraft, except as a fare -paying passenger; (b) A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or (c) An ultra light, hang-gliding, parachuting or bungi-cord jumping; 6. Travel in or upon: (a) A snowmobile; (b) Any two or three wheeled motor vehicle; (c) Any off -road motorized vehicle not requiring licensing as a motor vehicle; 7. Any Accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator's license; 8. That part of medical expense payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited); 9. Injury that is: (a) The result of the Covered Person being Intoxicated. ("Intoxicated" will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs); or (b) Caused by any narcotic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or inhaled, unless prescribed by a doctor; 10. Any Sickness, except infection which occurs directly from an Accidental cut or wound or diagnostic tests or treatment, or ingestion of contaminated food, 11. Expenses to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan; 12. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood; 13. Elective treatment or surgery, health treatment, or examination where no Injury is involved; 14. Injury sustained while in the service of the armed forces of any country. When the Covered Person enters the armed forces of any country, we will refund the unearned pro rata premium upon request; 15. Eyeglasses, contact lenses, hearing aids, braces, appliances, or examinations or prescriptions therefore; 16. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; 17. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; 18. Cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the body; 19. Any loss which is covered by state or federal worker's compensation, employers liability, occupational disease law, or similar laws; 20. The repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices; 21. Rest cures or custodial care; 22. The repair or replacement of existing dentures, partial dentures, braces or fixed or removable bridges; 23. Expenses incurred for an Accident or Sickness after the Benefit Period shown in the Schedule of Benefits; 24. Orthopedic appliances which are used mainly to protect an Injury so that a covered student can take part in interscholastic or intercollegiate sports; 25. Services and supplies furnished by the Policyholder's infirmary, its employees, or doctors who work for the Policyholder's; 26. Hernia of any kind; or any bacterial infection that was not caused by an Accidental cut or wound; 27. Prescription medicines unless specifically provided for under this Certificate. LIMITATIONS Any benefits payable under this Certificate will be limited to the following: (1) The medical benefits otherwise payable under this Certificate will be reduced by 50% if: GAC26932 (a) Excess insurance is provided under this Certificate; and (b) The Covered Person has coverage under another plan providing medical expense benefits; and (c) The other plan is an HMO, PPO or similar arrangement ("PPO-Preferred Provider Organization" means an Organization offering health care services through designated health care providers who agree to perform these services at rates lower than nonpreferred providers.); and (d) The Covered Person does not use the facilities or services of the HMO, PPO or similar arrangement for the provision of benefits. The Covered Person's limitation does not apply to emergency treatment required within 24 hours after an Accident which occurred outside the geographic area serviced by the HMO, PPO or similar arrangement. (2) Costs that exceed the Usual, Reasonable and Customary charges in the area where the services are furnished or supplies provided. Services, supplies and equipment must be: a) Medically necessary for the care or treatment of a covered Injury; b) Received while coverage is in force under this Certificate; and c) Rendered and/or prescribed by a licensed Doctor other than the Covered Person (or a member of his household or immediate family) in accordance with current medical standards and practices. (3) The application of the Coordination of Benefits or Non -Duplication of Benefits provision. (4) If the Covered Person is admitted into the Hospital on a Friday or a Saturday on a non -emergency basis and the procedure for which he is admitted is not performed on the day of or the day after admission, we will not pay the Hospital charges for room and board or miscellaneous Hospital charges for the initial Friday or Saturday preceding the procedure. PREMIUM PROVISIONS GRACE PERIOD: A grace period of 31-days is granted for each premium due after the first premium due date. Coverage will stay in force during this period unless notice has been sent, in accordance with the POLICY TERMINATION provision, of the intent to terminate coverage under this Certificate. Coverage will end if the premium is not paid by the end of the grace period. PREMIUMS: Premium due dates are the first of every month. Premium payment made in advance or for more than a one month period will not affect any provisions of this Certificate with regard to change. Failure by the Certificateholder to pay premiums when due or within the grace period shall be deemed notice to us to terminate coverage at the end of the period for which premium was paid. CHANGES IN RATES: We have the right to change the premium rates on any premium due date: (1) After the first 12 months insurance is in effect; (2) Coinciding with a change in the coverage provided or classes eligible; or (3) Coinciding with a change in the risks we have assumed. We will give 31 days written notice of any change under (1) above. Notice will be sent to the Certificateholder's most recent address in our records. GENERAL PROVISIONS ENTIRE CONTRACT; CHANGES: GAC26932 This Certificate, the application of the Certificateholder (if any, a copy of which is attached), endorsements, riders and attached papers constitute the entire contract between the parties. If an application of a Covered Person is required, the application of any Insured, at our option, may also be made a part of this contract. All statements made by the Certificateholder or by a Covered Person are deemed representations and not warranties. No such statement will cause us to deny or reduce benefits or be used as a defense to a claim unless a copy of the instrument containing the statement is or has been furnished to such person; or, in the event of his death or incapacity, his beneficiary or representative. After 2-years from the Covered Person's effective date of coverage, no such statement, except in the case of fraud or with respect to eligibility for coverage, will cause such coverage to be contested. No change in this Certificate will be valid until approved by one of our executive officers. This approval must be endorsed on or attached to this Certificate. No agent may change this Certificate or waive any of its provisions. WORKERS' COMPENSATION INSURANCE: This Certificate is not in lieu of and does not affect any requirement for coverage under any Workers' Compensation Insurance. CERTIFICATES OF INSURANCE: A certificate of insurance will be delivered to the Certificateholder for delivery to a Covered Person. Each certificate will list the benefits, conditions and limits of the Certificate. It will state to whom the benefits will be paid. CONFORMITY WITH STATE STATUTES: Any provision of this Certificate in conflict, on the Effective Date of this Certificate, with the laws of the state where it is delivered, is amended to conform to the minimum requirements of such laws. CLAIM PROVISIONS NOTICE OF CLAIM: Written notice must be given to us within 30 days after a covered loss occurs or begins or as soon as reasonably possible. Notice can be given at our administrative office as shown on the cover page or to our agent. Notice should include the Certificateholder's name and number and a Covered Person's name and address. CLAIM FORMS: When we receive the notice of claim, we will send forms for filing proof of loss. If claim forms are not sent within 15 days after notice is given, the proof requirements will be met by submitting, within the time required under PROOF OF LOSS, written proof of the nature and extent of the loss. PROOF OF LOSS: Written proof of loss must be furnished to us in the case of a claim for loss for which this Certificate provides periodic payment contingent upon continuing loss within 90 days after the end of the period for which we are liable. Written proof that the loss continues must be furnished to us at intervals required by us. In case of claim for any other loss, proof must be furnished within 90 days after the date of such loss. If that is not reasonably possible, we will not deny or reduce any claim if proof is furnished as soon as reasonably possible. Proof must, in any case, be furnished not more than a year later, except for lack of legal capacity. TIME OF PAYMENT OF CLAIMS: Benefits due under this Certificate for a loss, other than a loss for which this Certificate provides installments, will be paid immediately upon receipt of due written proof of such loss. Subject to written proof of loss, all accrued benefits for loss for which this Certificate provides installments will be paid Monthly; any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of a written proof of loss, unless otherwise stated in the Description of Benefits. PAYMENT OF CLAIMS: GAC26932 Benefits for a Covered Person's loss of life will be paid to the beneficiary named in our records, if any, at the time of payment. The benefits can be paid in one sum or, at a Covered Person's written request, in accordance with one of our settlement plans. If a Covered Person has not requested any settlement plan, the beneficiary can do so in writing after a Covered Person's death. If there is no named beneficiary or surviving beneficiary, a Covered Person's loss of life benefits will be paid in one sum to the first surviving class of following in the order shown below: (1) The beneficiary named to receive a Covered Person's proceeds; (2) Spouse; (3) Child or children; (4) Mother or father; (5) Sisters or brothers; or (6) The estate of a Covered Person. If we are to pay benefits to the estate or to a person who is incapable of giving a valid release, we may pay up to $1,000 to a relative by blood or marriage whom we believe is equitably entitled. This good faith payment satisfies our legal duty to the extent of that payment. Any other accrued benefits which are unpaid at a Covered Person's death may, at our option, be paid either to his beneficiary or to his estate. All other benefits, unless specifically stated otherwise, will be paid to a Covered Person. PAYMENT OF CLAIMS: OTHER BENEFITS: All other benefits will be paid to the Covered Person, if he is living, if not, we will pay his beneficiary or his estate CHANGE OF BENEFICIARY: (Applicable only if an Accidental Death or Dismemberment benefit is provided) The Insured can change the beneficiary at any time by giving us written notice. The beneficiary's consent is not required for this or any other change which a Covered Person may make unless the designation of beneficiary is irrevocable or otherwise required by law. CONDITIONAL CLAIM PAYMENT: If a Covered Person incurs expenses for Injuries received in a covered Accident, and in our opinion a third party may be liable, we will pay benefits if: (1) The Covered Person first agrees in writing to refund the lesser of: (a) The amount we actually paid for such expenses; or (b) The amount actually received from the third party for such expenses; and (2) The third party's liability is determined and satisfied whether by settlement, judgment, arbitration or otherwise However, prior to our payment of benefits under this Certificate, if the third party's liability is satisfied in an amount less than the benefits payable under this Certificate, we will pay the difference. PHYSICAL EXAMINATION AND AUTOPSY: We will pay the cost and have the right to have the Covered Person examined as often as reasonably necessary while the claim is pending. We can have an autopsy made at our expense unless prohibited by law. (Autopsies are not permitted to be required in Massachusetts, Mississippi and South Carolina.) RECOVERY OF BENEFITS: We reserve the right to recover from a Covered Person any benefits we have paid to him for injuries: (1) Received in a covered Accident; and (2) Which are covered under: (a) workers' compensation or similar statutory remedies available under law; or b) Any employer's liability Insurance. It will be assumed that the Covered Person is in receipt of such benefits unless he gives us proof such benefits have been denied to him. SUBROGATION: GAC26932 If we have paid benefits to a Covered Person for Injuries received in a covered Accident, and in our opinion a third party may be liable, we will be subrogated to the extent of such payment and to all of the rights of the Covered Person regarding the recovery of benefits paid or to any settlement or judgment which results from the exercise of these rights. The Covered Person agrees to sign papers and do whatever else is necessary to transfer his rights to us. We will exercise such rights on his behalf. He further agrees to furnish us with all relevant information and documents. LEGAL ACTIONS: No action at law or in equity shall be brought to recover benefits under this Certificate less than 60 days after written proof of loss has been furnished as required by this Certificate. No such action shall be brought more than 3 years after the time written proof of loss is required to be furnished. GAC26932 When used throughout this document "The Company", "Our", "We", or "Us" means: ❑ United States Fire Insurance Company PRIVACY POLICY AND PRACTICES The Company values your business and your trust. In order to administer insurance policies and provide you with effective customer service, we must collect certain information about our customers. We want you to know that we are committed to protecting your private information and we will comply with all federal and state privacy laws. Below is a Privacy Notice describing our policy regarding the collection and disclosure of personal information. Please review this Notice and keep a copy of it with your records. Your Privacy is Our Concern When you apply to The Company for insurance or make a claim against a policy written by The Company, you disclose information about yourself to us. There are legal requirements governing the collection, use, and disclosure of such information. The Company maintains physical, electronic, and procedural safeguards that comply with state and federal regulations to guard your personal information. We also limit employee access to personally identifiable information to those with a business reason for knowing such information. The Company instructs our employees as to the importance of the confidentiality of personal information, and takes measures to enforce employee privacy responsibilities. What kind of information do we collect about you and from whom? We obtain most of our information from you. The application or claim form you complete, as well as any additional information you provide, generally gives us most of the information we need to know. Sometimes we may contact you by phone or mail to obtain additional information. We may use information about you from other transactions with us, our affiliates, or others. Depending on the nature of your insurance transaction, we may need additional information about you or other individuals proposed for coverage. We may obtain the additional information we need from third parties, such as other insurance companies or agents, government agencies, medical personnel, the state motor vehicle department, information clearinghouses, credit reporting agencies, courts, or public records. A report from a consumer reporting agency may contain information as to creditworthiness, credit standing, credit capacity, character, general reputation, hobbies, occupation, personal characteristics, or mode of living. What do we do with the information collected about you? If coverage is declined or the charge for coverage is increased because of information contained in a consumer report we obtained, we will inform you, as required by state law or the federal Fair Credit Reporting Act. We will also give you the name and address of the consumer reporting agency making the report. We may retain information about our former customers and may disclose that information to affiliates and non -affiliates only as described in this notice. To whom do we disclose information about you? We may disclose all the information that we collect about you, as described above. We may disclose such information about you to our affiliated companies, such as: • Insurance companies; • Insurance agencies; • Third party administrators; • Medical bill review companies; and • Reinsurance companies. We may also disclose nonpublic personal information about you to affiliated and nonaffiliated third parties as permitted by law. You have a right to access and correct the personal information we collect, maintain, and disclose about you. How to contact Us GAC26932 You may obtain a more detailed description of the information practices prescribed by law by contacting us at the address below. Remember to include your name, address, policy number, and daytime phone number. Privacy Policy Coordinator Fairmont Speciality 5 Christopher Way, 3rd Floor Eatontown, New Jersey 07724 GAC26932 When used throughout this document "Company", "Our", "We", or "Us" means: ❑ United States Fire Insurance Company GRIEVANCE PROCEDURES When you submit a claim and that claim is denied, we will provide a written statement containing the reasons for the Adverse Determination. You have the right to request a review of any Company decision or action pertaining to our contractual relationship and to appeal any adverse claim determination we've made by filing a Grievance. These procedures have been developed to ensure a full investigation of a Grievance through a formal process. DEFINITIONS A "Grievance" is a written complaint requesting a change to a previous claim decision, claims payment, the handling or reimbursement of health care services, or other matters pertaining to your coverage and our contractual relationship. An "Adverse Determination" is a determination by the Company or its designated utilization review organization that (i) a service, treatment, drug, or device, is experimental, investigational, specifically limited or excluded by your coverage; or (ii) a facility admission, the availability of care, continued stay or other health care services proposed or furnished have been reviewed and, based upon the information provided, does not meet the contractual requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness and therefore, the benefit coverage is denied, reduced or terminated in whole or in part. INFORMAL GRIEVANCE PROCEDURE You, your authorized representative, or a provider acting on your behalf may submit an oral complaint to us within 60-days after an event that causes a dispute. Telephoning allows you to discuss your complaint or concerns and gives us the opportunity to immediately resolve the problem. If we don't have all the information necessary to review your complaint, we will request any additional information within 5 business days of receiving your complaint. After we receive all the necessary information, we will provide you, your authorized representative, or a provider acting on your behalf with our written decision within 30-days after receiving the complaint and all necessary information. If the problem cannot be resolved in this manner, you still have the right to submit a written request for the complaint to be reviewed through the Formal Grievance Procedure, as outlined below. FORMAL GRIEVANCE PROCEDURE A formal Grievance may be submitted by you, your authorized representative, or in the event of an Adverse Determination, by a provider acting on your behalf. If you file a formal Grievance, you will have the opportunity to submit written comments, documents, records and other information you feel are relevant to the Grievance, regardless of whether those materials were considered in the initial Adverse Determination. First Level Review Within 3 working business days after receiving the Grievance, we must acknowledge the Grievance and provide you, your authorized representative or a provider with the name, address, and telephone number of the coordinator handling the Grievance and information on how to submit written material. The person(s) who reviews the Grievance will not be the same person(s) who made the initial Adverse Determination. During the review, all information, documents, and other materials submitted relating to the claim will be considered, regardless of whether they were considered in making the previous claim decision. The Insured will not be allowed to attend, or have a representative attend, a First Level Review. The Insured may, however, submit written material for consideration by the reviewer(s). Grievance When the Grievance is based in whole or in part on a medical judgment, the review will be conducted by, or in consultation with, a medical doctor with appropriate training and expertise to evaluate the matter. Following our review of your Grievance, we must issue a written decision to you and, if applicable, to your representative or provider, within 20-days after receiving the Grievance. The written decision must include: (1) The name(s), title(s) and professional qualifications of any person(s) participating in the First Level Review process. (2) A statement of the reviewer's understanding of the Grievance. (3) The specific reason(s) for the reviewer's decision in clear terms and the contractual basis or medical rationale used as the basis for the decision in sufficient detail for the Insured to respond further to our position. (4) A reference to the evidence or documentation used as the basis for the decision. (5) If the claim denial is based on medical necessity, experimental treatment or similar exclusion, instructions for requesting an explanation of the scientific or clinical rationale used to make the determination. (6) A statement advising you of your right to request a Second Level Review, if applicable, and a description of the procedure and timeframes for requesting a Second Level Review. Second Level Review The Second Level Review process is available if you are not satisfied with the outcome of the First level Review for an Adverse Determination. Within ten business days after receiving a request for a Second Level Review, we will advise you of the following: (1) the name, address, and telephone number of a person designated to coordinate the Grievance review for the Company; (2) a statement of your rights, including the right to: • attend the Second Level Review • present his/her case to the review panel; • submit supporting materials before and at the review meeting; • ask questions of any member of the review panel; • be assisted or represented by a person of his/her choice, including a provider, family member, employer representative, or attorney. • request and receive from us free of charge, copies of all relevant documents, records and other information that is not confidential or privileged that were considered in making the Adverse Determination. We must convene a review panel and hold a review meeting within 45-days after receiving a request for a Second Level Review. We will notify you in writing of the meeting date at least 15-days prior to the date. The review meeting will be held during regular business hours at a location reasonable accessible to you. In cases where a face-to-face meeting is not practical for geographic reasons, we will offer you the opportunity to communicate with the review panel at our expense by conference call or other appropriate technology. Your right to a full review may not be conditioned on whether or not you appear at the meeting. If you choose to be represented by an attorney, we may also be represented by an attorney. If we choose to have an attorney present to represent our interests, we will notify you at least 15 working days in advance of the review that an attorney will be present and that you may wish to obtain legal representation of your own. The panel must be comprised of persons who: (1) were not previously involved in any matter giving rise to the Second Level Review; (2) are not employees of the Company or Utilization Review Organization; and (3) do not have a financial interest in the outcome of the review. A person previously involved in the Grievance may appear before the panel to present information or answer questions. All persons reviewing a Second Level Grievance involving a Utilization Review non -certification or a clinical issue will be providers who have appropriate expertise, including at least one clinical peer. If we use a clinical peer on an appeal of a Utilization Review non -certification or on a First Level Review, we may use one of our employees on the Second Level Review panel if the panel is comprised of 3 or more persons. Grievance We must issue a written decision to you and, if applicable, to your representative or provider, within 10 business days after completing the review meeting. The decision must include: (1) the name(s), title(s) and qualifying credentials of the members of the review panel; (2) a statement of the review panel's understanding of the nature of the Grievance and all pertinent facts; (3) the review panel's recommendation to the Company and the rationale behind the recommendation; (4) a description of, or reference to, the evidence or documentation considered by the review panel in making the recommendation; (5) in the review of a Utilization Review non -certification or other clinical matter, a written statement of the clinical rationale, including the clinical review criteria, that was used by the review panel to make the determination; (6) the rationale for the Company's decision if it differs from the review panel's recommendation; (7) a statement that the decision is the Company's final determination in the matter; (8) notice of the availability of the Commissioner's office for assistance, including the telephone number and address of the Commissioner's office. EXPEDITED REVIEW You are eligible for an expedited review when the timeframes for an Informal, formal First Level review or Second Level review would reasonably appear to seriously jeopardize your life or health, or your ability to regain maximum function. An expedited review is also available for all Grievances concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility. A request for an expedited review may be submitted orally or in writing. An expedited review must be evaluated by an appropriate clinical peer in the same or similar specialty as would typically manage the case being reviewed. If we don't have the information necessary to decide an appeal, we will send you notification of precisely what is required within 24-hours of our receipt of your Grievance. All necessary information, including our decision, will be transmitted by telephone, facsimile, or the most expeditious method available. Provided we have enough information to make a decision, you, your authorized representative, or a provider acting on your behalf will be notified of the determination as expeditiously as the medical condition requires, but in no event more than 72-hours after the review has commenced. Written confirmation of our decision will be provided within 2 working business days of the decision and will contain the same items described in the written decision requirements for First Level reviews. If the expedited review does not resolve the situation, you, your representative or a provider acting on your behalf may submit a written Grievance. We will not provide an expedited review for retrospective reviews of Adverse Determinations Grievance CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (X) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pro Asions or the agreement will automatically become void. Signature of Applicant gaz Date 9/11/21 Print Name Jeff Tiddens Agreement for; -El Segundo Inline Hockey Association Dated: 9-20-21 Reviewed by: