Loading...
PROOF OF INSURANCE (2024 - 2024)... ............... ...... --- --------------------- ---- ........... ... ........ ...... .. . . ................ . .. . .. .... . ...... . . .. .. ......... . . ............ . . . . . . ........... . . . DATE pMIWDOMVYY) CERTIFICATE OF LIABILITY INSURANCE 04WM24 ...... . . . i ............. ........... ........ ... ... . ............... ...................... . .... . . . . . ....... . ............. . � -- -1 11111-1-11 - L - 11 ---- . ...... . . THIS, CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW., THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 89TWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ------------- ... . ..... . ........... ............. . .. . . ........... holder is an AUDI TIONAL IINSURIED, the poky(les) must be endorsed. It SUIBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer 16ghts to the certificate holder in lieu of such endorsament(s). Pi&-- - - . .......... ... .. ....... .. . DUCER CONTACT NAZEi . .. . ....... -- ...... ...... ......... FAX The Camp Team, ILLC 80,01747-9573 303-422-1276 9015 Wads warfli Parkwa,y, EAAIL Ir ADDRESS Suite 3820, Pad TA � �,kf ,,fORDIING COVERAGE NSURER ..... . . . .. .. ...... .. INSURER A Texas Insuirance CRTpAriy ............ . 1.1.6543 . . ........ - ------- 0'ry of Ef Segundo,1NAMJIRERB RC:� 350 Main Mreft E'4 Segundo, CA, 910245 -- ---------- - - ------- - .......... INSURER F; COVERAGES CERTIFICATE NUMBEW, A-SP-SU-24-04-04-302043 REVISION NUMBER: . . ....... .. .... . ... . .... ... . . . ..... ... . ..... -- ,ri,-as Is w cirp riry nor 9,r qE P8LI4.'IES1 OF INSURANIA-, 00 En BU OW HAVE BT,-,r,,N aAxr,� ra n wt wsuREQ, NAMCD AW I'VE C OR IMF POLCM Pr,,400 ROXCM FO NO rVWM1,*i7ANLqN1U ANY THE TERMS, . . .......... ADOL SM FaVy kw I, .A=- TYPE ".w on.. .......... -.4iffivaty" — ------- GENERAL UABILITY fACH OCCURRENCE A N N 8FSraF11NVW301-M02-02 041OW2024 121112024 - ----- . . ..... �'H' LIAMAiGE TO NRCMISCS x CONIMENCIAL. GENERAL LIABILITY I; 3�00,000,00 pq��7 ... .. . . . ...... . ........ CA'ANSWAADE, El OrCUN WT..). F XP �.801.y mlw! p: - ---- - - ------ - - - x INCUDES AIM TIC PARTICIPANTS S2&AfA4ll.,_�,,AIIVINJIJRY S 11 Z10,0010 .00 GENERAL AG(3Rr,0ATL- AG s 2 001Q —009,pq OUCY FRDJEC11 LOC 57 P IF. ............ AUTOMOBILEIIIANUtY COMBNED SINGLV, LIIMI I' 7-1 CEv ard: darri) ANY AUro 1, M` 0 AUTGS . . . ................... . .. ............... . - ............. ALA !)!�v�tqcv NON 0100411: �") Aui (,w5 A011DIE!I q0MLY NJURY (Pet arx4AM) I'S .. ..... .. .... ............ . . . . . ....... 5CO1dC)rJI+A) AUTOS -2!E'A5r40nQ ......... . . . . . . . . . ....... i ....... . . .. ............ — ------- --.............................. — — ---- . ..... . . . . ...................... . . . ...... . . ........ CACH OCQJRRCNCt-`_ MOKE, . . .... . ....... . ........... . .......... . ...... E22 ................. ----- ----- EXCESS L" C�WS-AAADE ... . . .............. . . --- - - - - ---------------- -- DIEDUCTIBLE . .......... ----- . .......................................................... . . . . ...... ........ g XTI, . ......... - . . ..... AWEIMLOYSOUASIXY ....... .... -. ......... ANY 'OMM EM LDc=P w"Arryi1w NIA 9 yes, deeciNv under . .......... SPECIAL P4�OVJRJONS below .... . .......... ------ . . ........ . .. .. .. .. . . .......... . ......... OTHER A AbuselhhoWstahon M N 041OWT24 IZ3112024 Each OccwronwS 1100,LMJd IDo AggrcqaW SW 1U1 00 . .......... OESCRIPIrION OF OPERATIONS I LOCA'MONS f VENtrL.E5 (Attach ACORD tOl, AMItIonmi Remarks Schedu.... . ........le, 4 more spact is required) UabWty Vlolklq DeductbWS : $10 100 JaducNAe for Boddy Inpury and S $01010 00 per Prupwlly Danmqp OW"t ISO Cccu"wce bynii CO W 01 04 13 and uwnlbany's spm0ftforins, Coverwie foi, PwWpart LoIgal I-JablRY rw4jak" OW every paitaparO siWis atwaivwlroIena, RE Vtop,ilerad Otorra pair fldpaints 04KAI2024 - 12,11=9„ ER. ......................................... . . . . . . . . . . . . . ........... ............... . ......... .... . ... CERTIFICATE HOLDCANCELLATION CIt,y of LEI Segundo SHOULD ANY Of THE ABOVE 0EscBJaV0 POUCIES BE CAWFLUED REPORE THV EXIM"ATION DATE TWREOf, IN OTICE WILL BE DELIVERED INI Ar.COAJDANCE WTH THE PMACY PROMSIONS, 350 mam rplre0 AUTHON17.ED REPRESeNTATIVE 0 Segundo CA,902,45 Mark Dii Parno 02010RD CORPORATION. All rights reserved'. AC!ORD 1011 (20,08f0i) Thio ACORD niame and logo are registered marks ♦ ACORD UNITED STATES FIRE INSURANCE COMPANT Administrative Office � 5 Christopher Way - 31"Floor # Eatontown, N�J 07724 fWJ A.4.21117;; `4111 11 ii 11�� �� iiitii iil�� i 11� 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, when duie, and complietion of an Application. This Certificate is a part of, and is glovemeld by, a Group Poiicy. 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 firno. The narnie of the Group Policyholder is shown in the Schedule. This Certificate has been issued to you, the Certiflcateholder, as Participant under the Group Policy, in accordance with the terms, conditions, and limitations, of the Group Policy. If for any reason You are not satilsfied with this Certificate, You may return it to us, within 1 0-days after You receive it. Upon, receipt, we wili refund ainy pro miurn paidi and the Certificate will be deerned void), just as though it had never been issued, :I -.# �-. a 4 0- 1 M [.94,111twilIM, R 7MMM., W71 -.114:41111101:4 Signed for The United States Fire Insurance Company By: Marc J. Adlee James Kraus Chairman, and CEO Secretary 11 Il A k, k The provisions of this Certificate appear within, in the following order, Definitions Scope • Coverage , t$fFK#, Exclusions Additional Exclusions Limitations Premium Provisions General Provisions Clairn Provisions COVERAGE IS PROVIDED UNDER GROUP POLICY NUMBER- AH-GA26932-001 ISSUED TO GROUP POLICYHOLDER. The Group and Blanket Accident & Health Insurance Trusi . . . . ...... CIERTIFICATEHOILDdo CERTIFICATE NUMBER: US21"036i I 114411AINIRY-NIZ1111149 9;101 1111YJA 08 Apr 20:24 CERTIFICATE EXPIRATION DATE, 31 Dec 2024 BENEFIT PERIOD-. Provided treatment begins within 30 days from the date of Injury,, Benefits are payable for 52 we�eks 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. $501000 10"" of Usual, Reasonable & Customary ChaLqes, �URC) LIFETIME MAXIMUM BENEFIT AMOUNT: 525000 MEDICAL EXPENSE BENEFIT I lois,pital Room & Board Daily Maximum Benefit Amount: IURC Intensive Care Room & Board Dailly Maximum BenefW IURC Hospital Miscellaneous Maximum Benefit Amount: URC Outpatient Pre -Admission Testing Benefit Arriouft URC Outpatient Hospital Emergency Room Treatment Maximum Benefit Amount: LIRC Surgical Benefits Primary Surgeons Maximurn Benefit Amouinit, URC Assistant Surgeon,, Second Surgiicall Opinion, Consultation Maximum Benefit: URC Anesthesia Maximum Benefit: URC Surgical Facility Maximum Benefit per Operating Session; URC Doctor's Visits In -Hospital Maximum Benefit: UIRC Office Visits Maximum Benefit: URC X-ray and Laboratory Maximum Benerit Amount: UIRC Nursing Maximum, Benefit Amouint: URC 292223=11'i Maximum Benefit Amount (Hospital Inpatient): UIRC Maximuirn Benefil Amount (Outpatient); URC Ambulance Maximum Benefit Amount: URC Medical Equipment Rental Charges Maximium Benefit Amounit: UIRC Mledical Services and Supplies Maximum Benefit Amount URC (Blood, Blood Transfusions, Oxygen): Dental Treatment For Injury Only UIRC Maximum, Benefit Amount: actual charges Out -Patient Prescription Drug Beneflit, ACCIDENTAL DEATH, DISMEMBERMENT, OR LOSS OF SIGHT $1010010 Principal Sum'. DEFINITIO�NS The terms shown below shell have the meaning given in, this section whenever they appear in this Certificate, Addlitionial terims may be defined within the provision: to which they apply. "Accident" means a sudden, unforeseeable extemal event whicK (1) Causes Injury to one or more Covered Persons; and (2) Occurs while coverage is in effect for the Covered' Person, � 11 �! 1 11 1 N I I I I I i ill I i I I ill I I i ill I i I ii iii � �!i OR I U ITW, M, IMMEMUM "Covered Person"" means a person eligible for coveragie 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 includle: (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 U'sual, 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, most 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 em,plloyee 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 primarilly and continuously engaged in providing medical care ands treatment to sick and injured persons on an inpatient basis,; (3) Is under the supervision of a staff of doctors; (4) Provides 24 hour inuirsing service by or under the supervision of a graduate registered nurse,, (R,N.), (5) Has medical, d lagnicis,tic and treatment facilities, with, major surgical facilities; ities; (a) On its premises; or (b) Available to it on a prearranged basis; and (6) Charges for its services, "Hospital"' does not ln6ude° (1) A clinic or facility for: (a) Convalescent, custodial, educational: or niuirsing cal (b) The aged, drug addicts or Alcoholics; or (c) Rehabifitatillon; or (2) A military or veterans hospital or a hospital contracted for or operated by a national government or its agency u6iess'. (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 Staymeans a M'iedic:aily Necessary overnight confinement in a Hospital when room and board and genera' nursing care are provided for which a per diem charge is made by the H�ospitaill. I ril III File E-44i l Sai U11VTt9ll F611b'i bitbW1114111 III 1 4"1 AeTll.� 11111GIZAIlTly dill lWaLCiRl k;lfll-V#XiF4I-f,5-a�-fO-I-(A�;OMnN3 of the Injuries wiil be considered onie linjury, "Medically Necessary" or "Medical Necessity" means the service or suppiy ils: (1), Prescribed by a Doctor for the treatment of the Injury; and (2') Appropriate, according to, conventional) medical practice for the Injury in the locallity in which the service or supply is given. "Nurse" means either a Iprofes,s,ional, licensed, graduate registered nurse (R.N,) or a professional, ()licensed practcal nurse (L.P. N.). guarom 0 fillme=-Lo III 1111*61 RODE111041l =.- V 1111][410903 drowmats I I Moll pi all lian lfMal"IZIAM ITALW1010i Bill V,&I 11111[sifill IN KOWTVA ill I "Student linfilinnal 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) ProVidles nursing services; and (4) Charges fair its services. "Student Infirmary" does riot Include: (1) Medical, diaginostic or treatment facilities with major surgical facilities: (a) On its premises; or (b) Available to, it on a prearranged bases„ or (2) in patient care, (No benefits are payable for services, supplies, or treatment in a Student Infirmary. This definition is applicable onil to its reference in the provision filled Additional Exclusions.) "Supervised or Sponsored Activity" means a Certificatehiolder or School authorized functiow (1) In which the Covered) Person participates; (2) Which is organized by or tinder its auspices; which is within the scope of customary activities for such entity "Usual, Reasonable and Customary" means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a)l Usually charged by the provider for the service or supply given-, and (b) The average, charged for the service or supply iln, the locality in which the service or supply Is received: or (2) With respect to treatment or dab meical services, treatment which is reasonie in rellationship, to the service or supply given and the severity of the condition, We will provide the benefits described in: this Certificate to all Covered Persons who suffer a covered loss whil (1) Is, within the scope of the DESCRIPTION OF BENEFITS PROVISIONS and results, directly and independently of disease or bodily infirmity, from an Injury whichis suffered in an Accidell (2) Occurs while the person is a Covered Person, under this Certificate; and (3), Is within the scope of the risks set forth in the DESCRIPTION OF HAZARDS provisions, Full Excess thedical Expense: 41110111:42M MIME w0 1 108 kil any), MY are in excessIll perlsjus F773WIFF Arovislon 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 tilmie 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. Eligibility; Persons eligible to be insured under this Certificate are those persons described as an ELIGIBLE CLASS on, the Applicafion. This inciudes 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, eligiible accordingw to the referenced date show in the Application,. Termination: Insurance for a, Covered Person, willl end on the earliest of: () 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 traiinlng; (3) The end of the period for which the last prern ium contribution is made; or (4) The date the Group Policy is terminated. Coverage under this provision will end on, the earlier of: (1) The date ending the six month, period immediately followr nq the last day the Covered Person was actively at work on a fuh time bases, or (2) The ends of the period for which, the llast premium is paid, HAZARD. SPORTS COVERAGE Subject to allll other provisions of this Certificate, coverage is, provided for a Covered Person while he is: (1) Taking part in: (a) A regularly scheduled athletic game or competition; or (b) A practice session for an athletic team or club; (2) Travelling to or from such a game, competition, or practice session, provided he is: (a) Traveling with the athletic team or club; and (b) Under the direct and immediate supervision of: (i) Theathleticteamorclub,-or (il) An adult authorized by the athletic team or club; or (3) Traveling directly, without interruption, (a) Between his home and a, scheduled game, competition or practice session (b) In a vehiicle which is (i) Designated or furnished by the athlefli; team or club; (K) Operated' by a properly licensed, adult driver, or (iii) Under the direct supervision of the athletic team or chub; or (o) In, a vehicie other than that described in, ()(b) when-, (i) Operated by a properly licensed! driveir; and (ii) Travel time does not exceed an, hour each: way. Travel time includes the time: (i) To or from home, a scheduled gairne, competition or practice session; (ii) Before required attendance time; (M) After the Covered Person is d ismissedl; and (iv) After the Covered Person completes extra duties assigned by the Scholod. Covered athletic games or competition are shown an the Schedule of Benefits. b-TIM-C t7f, r or of the sport, are, not covered. Uniess otherwise stated, we w1II pay benefits for a covered loss, o6ly once, even if coverage was provided under more than one Description of f iaizards. 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, Ellgible Expenses are those incurred fo.r (1), Hospital Room and Board ­­ charges for the most common semi private daily room rate for each day of the Hospital Stay, tip to the Maximum Daily Benefit Amount shown in the Schedule of Benefits for Hospital Room and Board. (2) Intensive Care Roorn, and Board - charges for each day of Intensive Care Unit confinement, up to the Daily Maximum Bilenefit Amount shown in the Schedule of Benefits for the Intensive Care Room and Board beneflit, This payment is in lieu of payment for the Hospital Roorn and Board charges for those dayis,. �3) Hospital Miscellaneous - charges during a Hospital Stay, up to the Maximurn Daily Benefit Amount shown in 1 : I the Schedule of Benefits for the Hospliall Miscellaneous benefit. Miscellaneous charges do net incl�udle charges i for telephone, radio or television, extra beds or cots, meals for gueststake home items, or other convenience tems, (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 Iper emergency shown in the Schedule of Benefits for the Outpatient Emergency Room Treatment benefit. (5) Surgical Benefits - charges for: I. A Doctor, for primary performance of a, surgical procedure,, up to the Maximuim 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 1 .57 times the siurgical procedure chiarge when more than one surgical procedure through different operating fields are performed duiringi the same surgical sivsslio-u (b) A Doctor, far: (i) assistant surgeon duties; (ii) a second surgical opiinion; or (H), cons,ulltation, up to the Maximum Benefit shown in the Schedule of Benefits for an Assistant Surgeon, Second Surgical Opinion, and Consultation, (c) Anesthesia and its administration, up to the Maximum Benefit Amount shown in the Scheduie of Benefits fcr the Anesthesia beneft. (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 IDoctor for other than pre or post Operative care:. (a) For in Hospital visits, up to the Maximum Benefit Amount shown, mn the Schedule of Benefits, for Dioctor's Visit — In -Hospital, (b) For office viisRs, up to the Maximum Benefit Amount shown in the Schedule of Benefits, for Cloctor's, Office Visits, Total visits per injury Wit 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), Nuirsing Services - Chargies 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. (19) Physiotherapy - Charges for p,hy'slothierapy- (a) While Hospital confined, up to the Maximum Benefit Amount shown in the Schedule of Benefits for the Hospital linpatient Physiotherapy benefit; (b), As an outpatient, up to, the Mlaximium Benefit Amount shown on the Schedule of Benefits for the Outpatient Physiotherapy benefit. Physiotherapy includes. (a), Heat treatment; (b) Diathenny; (c) Microthierm; (d) Ultrasonic; (e) Adjustment; () Manipulation; (g) Massage therapy and (h) Acupuncture, I otal treatment per Injury will not exceed the Maximum Benefit Amounts for Physiotherapy shown in the Schedule of Benefits. 110) Aimbulance - frorn the place where the! injury occurred to the Hospital, up to the Maximum Benefit Amount shown it 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 IMaxiimum Benefit Amount shown in the Schedule of Benefits for the Medical Equipment Rental benefit. (112) Medical Services and Supplies - Charges for medical services and supplies for. (a) Oxygen and its admirilstration; (b), Blood ands blood trainsfusions', up to the, Maxim uim Benefit Amount shown in the Schedule of Benefits, for the Medical Service & Supply benefit (13) Delntall Treatment - Charges for dental treatment for Injury to a tooth which was sound and natural at the time of Injury, up to the M� aximuim Benefit Amount shown In the Schedule of Benefits for the Dental Treatment benefit. The amounts payable Linder this Medical Expense (benefit could be greatly reduced if the Covered Person does not comply with, the requirements in the I-ImItations section of this Certificate. We will pay the Eligible Expenses, subject to the Deductible Amount andl Coinsurance Percentage shown in the Schedule of Berl if any, for a Prescription Drug or medication when prescribed by a Doctor on an outpatient basis, Pres,cription 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 fur the out patient use by the Covered'! Pe!rsonk (1) On or after the CoveiredlPeirson's Effective Datc 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, BEVEFIT A. BENEFITS FOR ACCIDENTAL DlEATHi DISMEMBERMENT, LOSS OF SIGHT If, within one-year from the date of an Accident covered by this Certificate, Injury from such Accident, results in Loss Misted below, we will pay the percentage of the IN Such 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 a mo�unt, the largest to which he Is entitled. This amount will not exceed the Principal Sum wNch 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 fHandl 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 One Hand Loss of One Foot Loss of Entire Sight of One Eye Loss of Thumb and Index Finger of the Same Hand Percentage of Principal -Sure 1001% 1001% 1001% 1001% 10011% 10011% 1001% 50% 50% 50% 25% l i "rimimmit 11; liar ilizinflilril ;rWTE-Wom Less of sigiht 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 a thumb and Index finger means complete Severance through or above the meitacarpophai,langeall joints (the joints between the fingers and M. "Severance" means the complete separation and dismemberment of the part from the body. 1«=111 I I I I I I I I I I I mow_. OM &.11*1 z Bot be paid for a Covered P'eirsion;"s loss whIch., Is caused by or results from the Covered Person's own: (a), Intentionally self inflicted Injurysuicide or any attempt thereat. (In Missouiri this applies only while sane.); (b) V'og or chemitalsubstance not prescribed by, aind taken according to, the directions of, a doctor (Accidental ingestion of a polsonioius substance is not excludeid,)4, (c) Commission or attempt to commit a fellony; (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 (he 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 Armedl 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; (di) Sickness, disease,, bodily or mental infirmity or medical or surgilcall treatment thiere,of, bacteria] or viral infection, regardless of how contracted, unless a Sickness Expense Rider is inforce, under this Certificate, This dloes 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 toss was caused by fire, heat, explosion or other physical! trauma which, was, a result of the release of nuclear energy; and' H. 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: 2!4 hours of the, start of the release. U 10 Lol k I L43 1. 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; Z 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; 3. Charges which. - (a) The Covered) Person would not have to pay if he 6d not have insurance: or (b) Are in excess of Usual, Reasonable and Customary charges. 4An 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 glicing, parachuting or bungi colydl juimpingµ 5Travel in or upon: (a) A snowmoblile; (b) Any two or three wheeled motor vehlcle;� (c) Any off road motorized vehicle not requiring licensing as, a motor vehicle; 6a Any Accident where the Covered Person is the operator of a motor vehicle and doles not possess a current and valid motor vehicle operators liceinse-, 7. That part of medlicail expense playable by any automobile insurance policy without regard to fault, (Does not apply in any state where prohibited); 6, Injury that is: (a) The resuilt of the Covered Person being Intoxicated. ("Intoxicated" wit] 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; 9, An Injury resulti ngi from participation in or practice for non School sponsored skiing, ice hockey, lacrosse, or soccer; 10, Expenses, to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan; 11, Blood or Blood plaisma, except for charges by a Hiospital for the processing or administration of blood;, 12. Elective treatment or surgery, health treatment, or examination where no Injury is involved; 13. 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 willl refund the unearned pro rata premium upon request; 14. Eyeglasses, contact lenses, hearing aids, braces, appliances, or examinations or prescriptions therefore; 15. Treatment in any Veterans Administration or FederM Hospital, except if there is a Ilegall obligation to pay,, 1& Treatment of templorornandibular joint (TMJ) disorders invdIving the installation of crowns, pontics, bridges or abultiments, or the installation, maintenance or removal of orthodontic or occluisa6 appliances or equifibration therapy; 17. Cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the tiody, 1& Any loss which is covered by state or federal worker's compensation, employers Iiiability, occupational disease! Iaw, or simitar laws; 19. The repair or replacement of ex!sUngi artificial limbs, orthopedic braces,, or orthotic devices; 20. The, repair or replacement of existing dentures, partial dentures, braces, or fixed or removable bridges; 21 Any sickness, except infection wh:ich occurs directly from, an Accidental cut or wound or diagnostic tests or treatment, or ingestion of contaminated food; 22, Expenses incurred for an Accident after the Berieflit Period shown in 1 ie Schedule of Benefits'. 21 Orthopedic appliances, which are used mainly to protect an Injury so that a covered student can take part in interscholastic or intercollegiate sports� 24Hernia of any kind; or any bacterial infection that was not caused by an Accidental cut or wound; AVJE�� 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%; (a) Excess insurance is provided under this, Certificate; and (b) The Covered Person has coverage uin:der another plan providing medical expense benefits; and (c) The other plan is an HMO, PPO or similar arrangement ("PP'O 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 rionpreferred oviders,); and (d) The Covered Person does not use the facilities or services, of the HMO, PIPO or similar arrangement for the provision of benefits. 'The 0olvered Person's limitation does not apply to emergency treatment required wiftni 24 hours after an Accident which occurred outside the geographic area serviced by the HMO, PP;O or simlWr arrangement 1 1 � I N 1 -11- 1 i I W1 IM FaOATMOVA-a :10170141 Z GRACE PERIOD: A grace period of 31i-days is granted for each prerniurn due after the first premium due date. Coverage will stay in force during this period unless notice has been sent, in accordance with the POLL TERMINATION provision, of the lnitent to terminate coverage under this Certificate. Coverage will end if the prerrium is niot paid by the end of the grace period. PREMMILS: =0 SIX Ulrlef I I'MU *1 NIVIM Ujui 31OUd per Palf 5111U1111 *U 11" 1 Pr premijurn 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. ENTIRE CONTRACT; CHANGES: This, Certificate, the application, of the Certificateh older (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 bemade a part of this contract. ,Alll statements made by the Certificateholdeir nor by a Covered Persons 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 beein 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 untR approved by one of ouir 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. RECORDS MAINTAINED: The Cerfificateholder or its, authorized administrator will maintain records of the essential features of each Covered Person's insurance under this Certificate. We shall be permitted to examine the Certificaitelholder's records relating to coverage under this Certificate. Examination may occur at any reasonable time up to the later of: (1) The two year period after the expiration of the Certificateholder's coverage', or (2) The final adjustment and settlement of all claims, under the Cerfificateholders coverage. REPORTING REQUIREMENTS - The Gertificateholder or its authorized agent must report to us, by the premium due date: (1) The names ofallll persons insured on the Effective IDate of this Certificate, (2) The names of all persoins, who are insured after the Effective Date of this Certificate; (3) The names of those persons, whose insurance has, teirrininatedl- and (4) Additional information required as agreed to by us and the Certificateholder. CONFORMITY WITH STATE STATU'TES� 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 re,quiirements of such taws. AVOIUU�* �* I � NOTICE OF CLAIM: Written notice must be given to us within 30 days (Ken:tucky - 60 days) after a covered loss occurs or begins or as; Solon as reasonably possible. Notice can be given at our administrative office as shown loin the cover page or to our agent. kictice-6kould include the Certificatel'idlder's name and niumber and: a Clovered Person's narne and address. CLAIM FOR,11 S When we receive the notice of daiim, we will send formis for filing proof of loss. if claim forms are not sent within 15 days after notice is, given, the proof reqe met by submittinigiwithin the time required under PROOF 01F LOSS, written proof of the nature and extent of the loss. PROOF OF LOSS* V In case of claim for any other loss, proof must be furnished: within 90 days after the date of such loss. Proof must, in any case, be furnished not more than a year tater, except for lack of legal capacity. TIME OF PAYMENT OF'CLAIMS-. a loss for which this Certificate nrovides installments, will be naid immediately upon, re!ceipit of due w6tten proof of such loss,. Subject to written proof of loss, W11 accrued benefits for loss for which this Certificate provides installments; wUl 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 Beinefits. PAYMENT OF CLAIMS: Benefits for a Covered Person's loss of life will The paid to the beneficiary named in our records, if any, at the time of payment. The benefits can be plaid in: one sum or, at a Covered Peirsons written request, in accordainice with one of our ipment lans, If a Covered Person has niotrevuested an%settlement Ian, the bleneficiary can do so, in writing after a Covered Pierson's death. If there is no named beneficiary or surviving beneficiary, a Covered Person's Ioss of life beriel will be paid in one sum to, the first surviving class of following in the order shown bel�ow.& (1) The beneficiary named to receive a Covered Person's proceeds, (2) Spouse; (3) Child or childrew, (4) Mother air faither; (5) S�sters or brothers; or (6) The estate of a Covered Persw,n. if we are to pay benefits to the estate or to a person whoincapable of giving a vaild release, we may pay up to $1,000 �Thi good faith la�,,ment satisfies ou r-LQ. 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 bleneficlary or to his estate. All other benefits, unless specifically stated otherwise, will be plaid to a Covered Per.son. PAYMENT OF CLAIMS: OTHER BENEFITS, A0 other beniefits will be paid to the Covered Person, if he �s living, if not, we will pay his beneficiary or his estate, 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 SUBROGATIO,N: 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 rwvilll be subrogated to the extent of such payment and to MI 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 righits to us. We will exercise such rights on his behalf. He further agrees to furnish us with ail relevant information and documents,. LEGAL ACTIONS: No action at law or in eqWty shalt be birougiht to recover benefits under thiis Certificate less than 610 days after written proof of loss has been furnished as required by this Ceirtificate. No such action shall be brought rniore than 3 years South Carolina: 6l years after the tinie written proof of loss is required to, be furnished. AWSREM11AF PROGRES'SirVE P.O. BOX 31260 MRACTAvto TMAIRA, Fl. 3:3631 NAIC (ornpa ny Code: I 1 10 Policy Numb,eir. 979,9103212 UnderwriVer by' Un,itpd hnamW Cas Co PolikyhrNder: P; styna RoddgUt12 Page 1 01 1 Ap6l 12, 2024 Customer Setvice 1-800-776-4137 24 1111Owars d fay, I ddy'5 di Week Krysty'na Rodriguez .7. I his vphficition of Ilnsuiranice is mint art insurance poNc�y and does not amend, extend or alter tie cowqe dfforcied b�y the policies hosted herein. Norwithstarding any rpiqlMirp.ment, term or condition of any cxitract or other document Mh respect to which this verification of insuram.p may be issued air may pertain, the insurance afforded by, the piNicies described herein is subject 10 all the terms, exclusions andl condhtions of the poilicles. Please accept this letter as verification of insurance for this policy, Policy and dlriver information pdicy 979903212 pofiq sutp.: Gilifornia Polio y perkut Al26, 2'024 Oct 26, 2'02'4 . .......... Fhie)re wa,.,,no)apse in,coveracty, r�yfingfts,Go0q puriod. ..... ........ Hfearve dwe! Apr 216,1210,24, . ..... ..... . Drivers: Krystyria Rodrigue? 6341D Green "alley Gir 312 Culver City, CA 90230 Vehicle Information ... .... ... .... ..... ... 1Jnmhowf LA i en nijrnber Coverage information Liallhifity To Others Bodily lnjiq IjabA'4y, Propeny Damage babifty ... ....... 2015 MiTSUIRISHI OUTIANIDER - - - - - - ----- S 15,000 each persoinA30, 000 each dUident $5,000, ea(h ac(udent zi� I affirm under penality of perjury under the laws of California one of the following declaration& ill 11 1 11 1 of Inbusinaii KelatiOns as prDwoeo 1:51 Jj! with the C�ty of El Segundo. L rt MS11 TO _J I have -and wffl mia;int InITTFUrs co on of the work for whiich the agreement with the City of El Segundo is executed, My workers' compienisation insurance carrier and policy number are, Carrier Policy Number Expiration Date ZMj�gent _ Phone # ('>Q I certify that, in the performance of the work set forth in the agireement with the City of El Segundo, 11 will not employ any pleirson in any manner so as to become subject to the workeirs' corniplensation laws of California, and agree that, if 1 should bleicome subject to the workers' compensation provisions of Labor Code § 37010 1 must immediately comply with, those provisiorts or the a reeimen't will automatically become void, 014.11.24 Signature of Applicant Date Print Namie . ........... Agreement for: Ki7styna, RodLriguez 0 707,711010022M Reviewed biyo. J"f�