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PROOF OF INSURANCE (2026)A DATE (MM/DDmYY> CERTIFICATE OF LIABILITY INSURANCE 03/19/2025 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT PHONE Ext): (516) 746 4141 ..... FAx N®.... ..-__.... Acrisure, LLC 365 CROSSWAYS PARK DR _rti._... _ WOODBURY, NY 11797 AIL ADDRESS ...... lemert@acrisure.com INSURER(S) AFFORDING COVERAGE— NAIC # INSURER A : INSURED ._.,... SPORTSAND...��. .............._...�.......V,...wwww___.................m RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ............... INSURER B t. ITS PARTICIPATING MEMBERS: Grace Marie Maxwell dba Athletic Grace Dance Studio INSURER C :. 113 El Segundo, CA 90245 INSURERE: '... INSURER F : i+c�Tl Lll�ATc LIIIAAOCO. (_A 01 AW)A9 Great American Insurance Company 1 16691 RFVH21nN NIINIRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE SUCH POLICIES.N. MAY _ ..,.. „•,"_ ,,,,,,,,„„,,,,_„ ........ AVE BEEN REDUCED BY PAID CLAIMS EXCLUSIONS AND CONDITIONS OFDS SUER INSERMS, TYPE OF INSURANCE µµµµWu... POLICY EFF POLICY EXP LIMITS NUMBER LTR INS�R WVO MMIDDIYYYY MMIOD GENERAL LIABILITY EACH OCCURRENCE $1,000,000 —�� - AI hT fdPNlrr{y $300000 X C;OMMERC:IALGENE::RAL.I..IP�fi01UT F'G E NO k .a (Ea rco rr ve;:ei .........,„„,,... - . CLAIMS MADE �� CbGEUR D MED EXP (Any one person) 000 -- X PAC 4725038 04/01 /2025 04/01 /2026 "" """"""""""""""""""" PERSONAL & ADV INJURY """" $1,000 000 A x HOST I -lc UOR LIABILITY INCL I DUD 12:00 AM 12:01 AM WW"""$10 X INCLLIOESAT LE1KtPARTICIPANTS GENERAL AGGREGATE ....... ....... $2,000,000 ,.,...... ..... —............. ._ GEN A,L,r REGATI UFAIT APPLIES S FIER PRODUCTS - COMPIOP AGG $2,000,000 PRC- X PCILICY 0',- L.. ✓" SIMd4•;.I...I::: Li1471T AUTOMOBILE LIABILITY (EaCIW311NE0 car;cid_,"J 1,.IVY AU-10 BODILY INJURY (Per person) .................�_-------- . .AU. OWNED SCHEDULED .......... ...... BODILY INJURY (Per PAW"rOS AUTOS aa:c4denY IUDN-OWINED PROPER, rY DAMAGE HRED A TC UMBRELLA LIAB OCCUFF, EACH OCCURRENCE .......... .......—., ..... li .......... EXCESS LIAB Ct..aWS-MADE ....�. .............. AGGREGATE DED RE I'EfN"NON fro 04/01/2025 04/01/2026 EACH OCCURRENCE $1,000,000 A Professional Liability X PAC 4725038 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 04/01 /2025 04/01 /2026 EACH OCCURRENCE $100,000 A Abuse and Molestation X PAC 4725038 12:00 AM 12:01 AM GENERAL AGGREGATE $300,000 AD&D AGGREGATE $500,000 03/31/ $100,000 A Accident/Medical Coverage BSR-F162220-01 12:00 AM 1201I AM PM 11:59 PM MAXIAD& MAXIMUM MEDICAL $100,000 DEDUCTIBLE $100 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covered Activities: Dance Studio - Ballet/Pointe, Ballroom, Tap, Jazz, Zumba (R), Cultural/Heritage Style Dancing, Modern, Wedding first dance The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named insured during the policy period. Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage rCRTICIreTF unl nFR CANCELLATION The City of El Segundo 350 Main Street El Segundo, CA 90250 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ac lri yu l-P , LA-0 ACORD 25 (2016/03) @ 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD rr RINSURANCE GROUP Property and Casualty PlJvacy Notice and Notice of InSUrance Information Practices WHAT DOES GREAT AMERICAN INSURANCE GROUP -PROPERTY AND CASUALTY MEMO ("GREAT AMERICAN") DO WITH YOUR PERSONAL INFORMATION? Financial companies choose how the,,, share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal lauv also requires us to tell VOU how we collect. share, and Protect your personal information. Please read this notice carefully% to understand what we do. The types of personal information we collect and share depend on the product or service you have with i us. This information can include: • Social Security,: Number. date of birth, income; • Policy coverage, premiums. account balances, payment and claim history: • Credit history. driving record. medical and ernploynnent information. Vvlhen you are no longer our customer. V e continue to share your infonnation as described in this notice. All financial companies need to share customers' personal information to operate their business. In the section below. %Ve list the reasons financial companies can share their customers' personal information the reasons Great American chooses to share: and whether you can limit this sharing. t a I For our everyday business purposes— 'v`o such as to process your transactions, maintain account(s). respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes— `elr:°,' to offer our products and services to you For joint marketing with other financial companies Yes No For our affiliates' everyday business purposes— Yes No information about Vour transactions and experiences For our affiliates' everyday business purposes— No We do riot share information about your creditworthiness For our nonaffiliates to market to you No We do not share Call 1-800-548-4269 or go to http..„ww.greatamericaninsurancegroup.com. T I II[I:, ro l/ I " 1 .:; (, J I ,, , l I I "� lip �lwf c� ,:s,,s ('iP &� killw-uVu_��iliV1pVI'll.`5 �l V 1 ��m JV[Ni, soa:d k 0 arninin I[ 6-1V I fi�im 11 �l 11 m Vzu H llorl:ed i1"ce!:3s ainiii V Ise, JDOVS�I,11 I I u u0 V1 I �itk lin J` C 1!, 4 Q'i", 11 !1 Ea,si Ives � hat coli I o"I 11 �l) uede� a P k:v,v, � hese !IT) lit �:!�s irich I�� I% ';C]MfNlk:q sal:�:°yuwds Dind secwpd flueTuid Nlil,illng�', Y�A- ::llso lillO, to �nfuillimtlun to Uhocvh�cl reed lt to lh) thoh �llll!�S, lf t I I I,�� r., t I e Ci .;C1n, I o 11 l"", ')t-I I c I , T I o II I 0 0 1 Tont markyong n(P,f�,��jrrienl hetween no 6,fl . ..... . .. ....... ....... . -7- -7 . .... . ..... We do not Igo dbse ym a 44l:h pnlfonnaticm wAh thiai podAs. unWss Mwnized by yo" or as allowed or NxV W Ly law We noy Isclose VchninfornOW as pomOtted by av,1, to undervvrOe ar adrinii-iister youll, p(Acy' caiirn cur ar"count, At may c0schse you; AnAnuhan to cunduct nwea= so long as no WMA data rnay.- be lcleoMfied io a the research shidy reporl, Wu nmy Mew aml cuned inknnatun that we odkid aWmA ywE To wwass ymaInkrmahan pAse sm KI a spad. M= reqwk to P&C I eyfl al Gireat Ari�eulcan h wwwwo Compm, W1 EaM FoW WeL COndamik Mq452024269; or W', PnmH U) chgMSIAq cnUL Please indbde jowlull nrumn addwaq dually ph= number and pohry murbw in your War, \Ahe ina"r M(-yUesir CMflier iNoirmation lo vMbe ym, Werifity, such on a copy of,�Ilour dlcense or in -their vaiid Iphoto ymi bdHwa any of yoAnkmnWn 4 AcomNeN okwunpM PWaSH k) �ISarld E�XlDlaiin what data you Mve ieeds conschng INMA moew ymu ii-ifornnairon, ff ojl(,'YTI'ee. uA,-iH coriiacl our veccrids Ilf v,,,e do not "q'ree, y'Olrii may file a YOW MaMmeM of dhpAe w1h um Upon ymy mqwsk ne aho noy provvide you,,vrth moie inforncition regairdling the cNscioswe inforioahon, Oicj� Aj'nunc"mi u ",cmp�jn:' I �Vliairlc'-' 1111'Iur'ii Ice (Al 1P, Iny Gmm Anwm on Mw awe Cvnkw', ynj t'er I Van. iurai ucH C 6r,�:�L Arn�-rican h:miv�cr, C�lnn,�m' � ;re,,ik Anfuoncan 11 v,Adfly fa suram',q irjpqPy Gi-at \n ery in nisu ao ncF� 4 "�, Y-,ii k G "�m Vin�:111 can Grc'at Ainl'sIrican am.Incml i:nnpi("'SuqJkn V in'-�� C"r'mrjpail Au"mn DnMe Usurmwo C vmpw! GAII Ckimj'�w')� ("'All conillpain", "I f�pujujr;.Ir jjp] hv, jjjjaCj' ni, S"Ir Great' %uruk.an nsumiK� e h", Rman I ewe K Lwn hNn3we Samaw hmuzho Ayncy Ac NOTICE OF PROTECTION PROVIDED BY CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION This notice provides a brief summary regarding the protections provided to policyholders by the California Life and Health Insurance Guarantee Association ("the Association"). The purpose of the Association is to assure that policyholders will be protected, within certain limits, in the unlikely event that a member insurer of the Association becomes financially unable to meet its obligations. Insurance companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The protection provided by the Association is not unlimited and is not a substitute for consumers' care in selecting insurers. This protection was created under California law, which determines who and what is covered and the amounts of coverage. Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations or the rights or obligations of the Association. COVERAGE - Persons Covered Generally, an individual is covered by the Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California. - Amounts of Coverage The basic coverage protections provided by the Association are as follows. Life Insurance Annuities and Structured Settlement Annuities For life insurance policies, annuities and structured settlement annuities, the Association will provide the following: Life Insurance 80% of death benefits but not to exceed $300,000 80% of cash surrender or withdrawal values but not to exceed $100,000 ., Annuities and Structured Settlement Annuities 80% of the present value of annuity benefits, including net cash withdrawal and net cash surrender values but not to exceed $250,000 The maximum amount of protection provided by the Association to an individual, for all life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of policies or contracts covering the individual. SDM-880 (Ed. 10/16) (Page 1 of 3) Health Insurance The maximum amount of protection provided by the Association to an individual, as of July 1, 2016, is $546,741. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer. Changes to this amount will be posted on the Association's website www.califega.org. COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE The Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy. The following policies and persons are among those that are excluded from Association coverage: - A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society If the person is provided coverage by the guaranty association of another state - Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual - Employer and association plans, to the extent they are self -funded or uninsured A policy or contract providing any health care benefits under Medicare Part C or Part D - An annuity issued by an organization that is only licensed to issue charitable gift annuities - Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract - Any policy of reinsurance unless an assumption certificate was issued . Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section 1067.02(b)(2)(C) SDM-880 (Ed. 10/16) (Page 2 of 3) NOTICES Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the Association, please visit the Association's website at www.califega.org, or contact either of the following: California Life and Health Insurance Guarantee Association P.O. Box 16860 Beverly Hills, CA 90209-3319 (323) 782-0182 California Department of Insurance Consumer Communications Bureau 300 South Spring Street Los Angeles, CA 90013 (800) 927- 4357 Insurance companies and agents are not allowed by California law to use the existence of the Association or its coverage to solicit, induce or encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and California law, then California law will control. SDM-880 (Ed. 10/16) (Page 3 of 3) Administrative Offices 301 East Fourth Street GREA' mERICAN Cincinnati, OH 45202 INSURANCE GROUP 1-513-369-5000 GREAT AMERICAN INSURANCE COMPANY CALIFORNIA IMPORTANT NOTICE Should you have a dispute concerning a claim, you should contact Great American Insurance Company first. Great American Insurance Company 300 East Main Street, Suite 314 Charlottesville, VA 22902 (800) 475-2691 If you are unable to resolve your dispute with the Company, you may contact the California Department of Insurance. California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Telephone: 1-800-927-HELP BSR 5007 (Ed. 01/15) Page 1 of 1 Administrative Offices � 301 E 4th Street BSR 5000 (Ed. 01 /15) \7RF.ATA &xcc lrnA ikr -'..— .1— a.,— GREAT AMERICAN INSURANCE COMPANY MASTER APPLICATION FOR BLANKET ACCIDENT INSURANCE Application is hereby made for a plan of blanket accident insurance based on the following statements and representations: 1. Identification of Policyholder Name of Applicant (Full Legal Name): Address of Applicant: 2. Classes of Eligible Persons Class Description of Class Grace Marie Maxwell dba Athletic Grace Dance Studio El -Segundo, CA 90245 1 All Participants and Staff of the Policyholder 3. Covered Activities Class 1: Dance Studio - Ballet/Pointe, Ballroom, Tap, Jazz, Zumba (R), Cultural/Heritage Style Dancing, Modern, Wedding first dance, While participating in scheduled, sponsored, and supervised activities of the Policyholder, including direct travel to and from said activities. 4. Benefits Accidental Death, Dismemberment Accident Medical Expense 5. Premiums: Class 1: It is hereby understood and agreed that the premium shall be $123.00 Such premiums are due and payable in the following manner: Yearly, on or before the Policy Effective Date. The terms and conditions of the requested plan of insurance may vary in certain states as required by the laws of those states. The terms of the policy when issued will govern. It is agreed the insurance applied for will not become effective unless: a) this application is received and approved by us based on our current rules and requirements; b) the policy is accepted by the applicant; and c) the required premium is paid when due. The Applicant represents the information contained in this application is true and correct and forms the basis of the requested insurance. NOTICE: This is a limited benefit policy. It does not provide comprehensive health insurance coverage. It does not satisfy the requirements of minimum essential coverage under the Affordable Care Act. BSR 5000 (Ed. 01/15) Page 1 of 2 For all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of committing a fraudulent insurance act, which is a crime. Signed for the Policyholder Title Date Signed by Licensed Resident Agent (Where Required by Law) BSR 5000 (Ed. 01/15) Page 2 of 2 Administrative Offices GRFATA X,rnn rd-e Xr � !01 h St 301E 4t k f S„ GREAT AMERICAN INSURANCE COMPANY SCHEDULE OF BENEFITS Policyholder: Grace Marie Maxwell dba Athletic Grace Dance Studio Policy Number: BSR-F162220-01 Policy Effective Date: 04/01/2025 Policy Termination Date: 03/31/2026 Classes of Eligible Persons Class Description of Class All Participants and Staff of the Policyholder BSR 5001 (Ed. 01 /15) Covered Activities Class 1: Dance Studio - Ballet/Pointe, Ballroom, Tap, Jazz, Zumba (R), Cultural/Heritage Style Dancing, Modern, Wedding first dance, While participating in scheduled, sponsored, and supervised activities of the Policyholder, including direct travel to and from said activities. Schedule of Benefits: Coverage Class 1: Aggregate Limit: Aggregate Benefit Maximum: Applies To: Accident Death and Dismemberment Benefits $500,000 Maximum Benefit Accidental Death, Accidental Dismemberment Benefits Principal Sum: Accidental Death & Dismemberment: $100,000 Maximum Benefit Incurral Period: Accidental Death & Dismemberment: 365 Days Accident Medical Expense Benefits Benefit Maximum: $100,000 Maximum Benefit Dental Maximum: Expenses incurred for dental services are also subject to the Benefit Maximum for Accident Medical Expense Benefits shown above. Deductible: $100 Maximum Benefit Period: 52 Weeks from the date of the covered accident Incurral Period: 90 Days Scope of Coverage: Excess Coverage BSR 5001 (Ed. 01/15) Page 1 of 2 Schedule of Affiliates Eligible Persons associated with any affiliate or subsidiary corporation of the Policyholder as of the Policy Effective Date are covered under the policy. Their coverage will begin and end in accordance with the Effective Date of Insurance and Termination Date of Insurance provisions in the policy. A list of these affiliates and subsidiaries must be kept on file with the Company. Newly Acquired Organizations. The premium shown on the schedule of benefits applies only to the Policyholder and any affiliates or subsidiary corporations covered on the Policy Effective Date. However, eligible persons associated with organizations acquired by the Policyholder during the Policy Term may be covered based on the following terms: The Policyholder must (1) report to Us within 30 days of the acquisition the name of the newly acquired organization and any underwriting information we may need to calculate the premium; and (2) pay the additional required premium, if applicable. Schedule of Policy Riders The following riders are attached to and made part of the policy's coverage as of the Policy Effective Date. Each rider is subject to all provisions, limitations and exclusions of the policy that are not specifically modified by the rider. Form Number Descriplign _Appli' bil.(ly .......... _............... ...._......_ ....... .... .... _ ..... ..._ SDM 526 (Ed. 02/19) ___ Privacy Notice and Notice of Insurance Information Practices Class 1 _..... ..i..� ............ _ ........... SDM 880 (Ed. 10/16) California LHIGA Disclaimer�ww Class 1 mm California Im ortant Notice _ Class 1 (Ed 01/15) Master Application for Blanket Accident Insura nce Class 1 BSR 5000.(.._ _ ... �....... BSR 5001 BEd. 01/15 Schedule of Benefits Class 1 1 / ._.k _...... � Policy ........_..�............. �....... �... s BSR 1021 (Ed. 01/15) California Amendatory Endorsement ..........._.____ Class BSR 7000 Ed. 01/15 Blanket Accident Polic Class 1 IL 72 68 Ed. 09/09 In Witness Clause Class 1 Premium: Class 1: It is hereby understood and agreed that the premium shall be $123.00 Such premiums are due and payable in the following manner: Yearly, on or before the Policy Effective Date. BSR 5001 (Ed. 01/15) Page 2 of 2 BSR 7000 (Ed. 01/15) GREAT AMERICAN INSURANCE COMPANY BLANKET ACCIDENT POLICY Policyholder: Grace Marie Maxwell dba Athletic Grace Dance Studio Type of Policy: BLANKET ACCIDENT POLICY Policy Number: BSR-F162220-01 Policy Effective Date: 04/01/2025 Policy Term: 04/01 /2025 — 03/31 /2026 State of Delivery: California This policy takes effect at 12:01 a.m. standard time on the Policy Effective Date shown above. It will remain in effect for the duration of the Policy Term shown above if the premium is paid according to the agreed terms. This policy terminates at 11:59 p.m. standard time on the last day of the Policy Term, unless the Policyholder and Great American Insurance Company agree to continue coverage under this policy for an additional Policy Term. The provisions and conditions set forth on the pages herein are a part of this policy as fully as if recited over the signatures below. This policy is governed by the laws of the state in which it is delivered. This is a supplement to health insurance. It is not a substitute for hospital or medical expense insurance, a health maintenance organization (HMO) contract, or major medical expense insurance. THE POLICY IS NOT IN LIEU OF WORKERS' COMPENSATION Excess Benefit Disclosure: This policy is secondary coverage to all other policies. Benefits may be reduced if a covered person is insured for medical benefits under the policy and is also covered under any other benefit plan. If the benefits to be paid under this policy plus the benefits to be paid under any other benefit plan would exceed covered expenses under this policy, benefits paid will be reduced by the amount of the excess. Please refer to Section VIII - Scope of Coverage for a complete description of excess benefits. THIS IS A LIMITED BENEFIT POLICY. IT PROVIDES BENEFITS FOR SPECIFIC LOSSES FROM ACCIDENT ONLY. BENEFITS ARE NOT PAID FOR LOSS DUE TO SICKNESS. PLEASE READ THE POLICY CAREFULLY BSR 7000 (Ed. 01/15) Page 1 of 13 Table of Contents SECTION I - DEFINITIONS.. ........... ............ ....... ....................... Page 3 SECTION II - POLICY EFFECTIVE AND TERMINATION DATES ..................................................Page 5 SECTION III -PREMIUM ....... ......... v a,...._. .............. .......... ...,,..................................... Page 6 SECTION IV - ELIGIBILITY FOR INSURANCE................................................................................ Page 6 SECTION V - EFFECTIVE DATE OF INSURANCE........................................................................ Page 6 SECTION VI - TERMINATION DATE OF INSURANCE.. ............... ........................ Page 6 SECTION VII - DESCRIPTION OF BENEFITS............................................................................... Page 7 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS ............................................. Page 7 ACCIDENT MEDICAL EXPENSE BENEFITS ....................................... .......................Page 8 SECTION VIII - SCOPE OF COVERAGE......................................................................................... Page 9 SECTION IX — EXCLUSIONS AND LIMITATIONS....................................................................... Page 10 SECTION X - CLAIM PROVISIONS .,....... ....., ........... m.............................. Page 12 SECTION XI - GENERAL PROVISIONS.....r..................................................................................Page 13 BSR 7000 (Ed. 01/15) Page 2 of 13 SECTION I - DEFINITIONS Throughout this policy, words and phrases that appear in bold have special meanings that can be found in the Definitions Section or in the specific Policy provision where those words appear. Accident means a sudden, abrupt, and unexpected event. Benefit Plan means a policy or other benefit or service arrangement for medical or dental care, or providing accident or health coverage, under any of the following: 1) individual, group or blanket coverage, whether on an insured or self - funded basis; 2) hospital or medical service organizations; 3) health maintenance organizations; 4) labor-management plans; 5) employee benefit organization plans; 6) association plans; or 7) any other "employee welfare benefit plan" as defined in the Employee Retirement Income Security Act of 1974, as amended. Coinsurance means the ratio by which we and the covered person share in the payment of covered expenses for medically necessary treatment. The percentage we pay is stated in the schedule of benefits. Covered Accident means an accident that occurs directly and independently of all other causes while coverage is in effect for a covered person resulting in a covered loss or injury under the policy for which benefits are payable. The covered person must be participating in a covered activity or specified hazard, as identified in the schedule of benefits, when the accident occurs. Covered Activity means those activities set out in the Covered Activities section of the schedule of benefits, with respect to which covered persons are provided accident insurance under the policy. Covered Expenses mean expenses actually incurred by or on behalf of a covered person for treatment, services or supplies covered by the policy. Coverage under the policy must remain continuously in effect from the date of the accident until the date treatment, services or supplies are received for them to be a covered expense. A covered expense is deemed to be incurred on the date such treatment, service or supply that gave rise to the expense or the charge was rendered or obtained. Covered Loss or Covered Losses means an accidental death, dismemberment or other injury covered under the policy. Covered Person means an eligible person, who enrolls for coverage, if required, and for whom the required premium is paid. Deductible means the dollar amount of a covered expense that must be incurred as an out-of-pocket expense by each covered person per injury before Accident Medical Expense Benefits and/or other optional benefits paid on an expense - incurred basis are payable under the policy. When a deductible applies, the amount will be shown in the schedule of benefits. Eligible Person means a person in a Class of Eligible Persons, as shown in the schedule of benefits. Free -Standing Ambulatory Surgical Center or Free -Standing Ambulatory Medical Center means a facility providing ambulatory surgical or medical treatment other than a hospital, clinic or physician's office. It must be qualified to provide the treatment under the standards set by the state in which it is located. Hospital means an institution that: 1. Operates as a hospital pursuant to law for the care, treatment, and providing of in -patient services for sick or injured persons; 2. Provides 24-hour nursing service by registered nurses on duty or call; 3. Has a staff of one or more licensed physicians available at all times; 4. Provide organized facilities for diagnosis, treatment and surgery, either: a. On its premises; or b. In facilities available to it, on a pre -arranged basis; 5. Is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a hospital used as such; and 6. Is not primarily a facility for alcohol, drug or behavioral treatment. Hospital Confined or Hospital Confinement means a stay of 24 or more consecutive hours as a registered resident bed -patient in a hospital. BSR 7000 (Ed. 01/15) Page 3 of 13 Immediate Family Member means a person who is related to the covered person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister and half-brother or half-sister), or child (includes a child legally adopted or a child placed for adoption but not yet adopted), or stepchild. Incurral Period means the time period within which the covered loss or covered expense must be incurred. The length of the incurral period will be shown in the schedule of benefits. The incurral period begins on the date of the covered accident causing the covered loss. Injury means bodily injury sustained by a covered person caused by a covered accident that: 1. Occurs while this policy is in effect as to the person whose injury is the basis of claim; 2. Occurs while the covered person is participating in a covered activity; 3. Occurs under the circumstances described in a hazard applicable to that person; and 4. Results directly and independently of all other causes in a covered loss under a benefit applicable to such hazard. See the schedule of benefits for applicability of hazards and benefits. All injuries sustained by one covered person in any one covered accident, including all related conditions and recurrent symptoms of the injuries are considered a single injury. Maximum Benefit Period means the period of time between the date of the covered accident causing the injury for which benefits are payable and the date after which no further expenses may be incurred for which Accident Medical Expense Benefits will be paid. The Maximum Benefit Period will be shown on the Schedule of Benefits. Medically Necessary or Medical Necessity means a treatment, service or supply provided to treat an injury that is: 1. Appropriate and consistent with the diagnosis and does not exceed in scope, duration, or intensity the level of care needed to provide safe, adequate, and appropriate treatment of the injury; 2. Is commonly accepted as proper care or treatment of the injury in accordance with the medical practices of the United States and federal guidelines; 3. Can reasonably be expected to result in or contribute to the improvement of the injury; and 4. Is provided in the most conservative manner or in the least intensive setting without adversely affecting the condition of the injury or the quality of the medical care provided. The fact that a physician may prescribe, order, recommend, or approve a treatment, service or supply does not, of itself, make the treatment, service, or supply medically necessary for the purpose of determining eligibility for coverage under this policy. Pre-existing Condition means a health condition for which a covered person has sought or received medical advice or treatment at any time during the 12 months immediately preceding his or her Policy Effective Date of coverage under this policy. Physician means a provider or practitioner who: 1. Is properly licensed or certified to provide care or treatment under the laws of the state where he or she practices; 2. Provides services that are within the scope of his or her license or certificate; and 3. Is neither the covered person nor a member of the covered person's household or an immediate family member. Policy means the contract issued by us to the Policyholder for the benefit of a covered person. Reasonable Charge means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. Schedule of Benefits means the benefits, benefit amounts, terms, limitations and provisions of coverage selected by the Policyholder which is attached to and made a part of this policy. Spouse means an adult person with whom the covered person enters into a marriage, civil union, or comparable relationship in a state or nation in which the marriage, civil union or comparable relationship is sanctioned by law and legally valid at the time it is entered into by the parties. BSR 7000 (Ed. 01/15) Page 4 of 13 Terrorism or Terrorist Acts means an activity that: 1. Involves any violent act or any act dangerous to human life and that threatens or causes Injury to persons; and 2. Appears in any way intended to: a) intimidate or coerce a civilian population; b) disrupt any segment of a nation's economy; c) influence the policy of a government by intimidation or coercion; or d) affect the conduct of a government by mass destruction, assassination, kidnapping, or hostage -taking; or e) respond to governmental action or policy. Terrorism or Terrorist Acts includes any incident declared to be an act of terrorism by an official, department, or agency that has been specifically authorized by federal statute to make such a determination. Terrorism or Terrorists Acts shall also include the use of any nuclear weapon or device or the emission, discharge, dispersal, release, or escape of any solid liquid or gaseous chemical or biological agent. We, Our, Us means Great American Insurance Company or its authorized agent. SECTION II - POLICY EFFECTIVE AND TERMINATION DATES Policy Effective Date. The policy begins on the Policy Effective Date at 12:01 a.m. standard time at the address of the Policyholder where this policy is delivered. Policy Termination Date. We may terminate this policy by giving 31 days advance notice in writing to the Policyholder. This policy may be terminated at any time by mutual written consent of the Policyholder and us. This policy terminates automatically on the earlier of: 1) the Policy Termination Date shown in the schedule of benefits; or 2) the premium due date if premiums are not paid when due. Termination takes effect at 11:59 p.m. standard time at the Policyholder's address on the Policy Termination Date shown in the schedule of benefits. BSR 7000 (Ed. 01/15) Page 5 of 13 SECTION III - PREMIUM Premiums. The premiums for this policy will be based on the rates currently in effect, the plan and amount of insurance in effect. Changes in Premium Rates. We may change the premium rates from time to time with at least 31 days advanced written notice. No change in rates will be made until 12 months after the Policy Effective Date. An increase in rates will not be made more often than once in a 12 month period. However, we reserve the right to change rates at any time if any of the following events takes place: 1. The terms of the policy change. 2. A division, subsidiary, affiliated organization, or eligible class is added or deleted from the policy. 3. There is a change in the factors bearing on the risk assumed. 4. Any federal or state law or regulation is amended to the extent it affects our benefit obligation. If an increase or decrease in rates takes place on a date that is not a premium due date, a pro rata adjustment will apply from the date of the change to the next premium due date. Payment of Premium. The first premium is due on the Policy Effective Date. After that, premiums will be due at the rates and manner described in the schedule of benefits unless we agree with the Policyholder on some other method of premium payment. If any premium is not paid when due, the policy will be canceled as of the premium due date, except as provided in the Grace Period provision. Grace Period. Unless, not less than 10 days prior to the premium due date, we have delivered to the Policyholder or mailed to the last known address shown by our written records notice of our intention not to renew this policy beyond the period for which premium has been accepted, a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period this policy will continue in effect. The policy will remain in effect during the grace period. If the required premiums are not paid during the policy grace period, insurance will end on the last premium due date on which required premiums were paid. The Policyholder will be liable to us for any unpaid premium for the time the policy was in effect. SECTION IV - ELIGIBILITY FOR INSURANCE Each person in one of the Classes of Eligible Persons shown in the schedule of benefits is eligible to be insured on the Policy Effective Date. We maintain the right to investigate eligibility status and attendance records to verify eligibility requirements are met. If we discover the eligibility requirements are not met, our only obligation is to refund any premium paid for that person. SECTION V - EFFECTIVE DATE OF INSURANCE Covered Person's Effective Date. A covered person's coverage under this policy begins on the latest of: 1. The Policy Effective Date as shown in the schedule of benefits; 2. The date the person becomes a member of one of the Classes of Eligible Persons shown in the schedule of benefits; 3. If individual enrollment is required, the date written enrollment is received by us; or 4. The date on which the first premium payment is received by us on or before its due date. SECTION VI - TERMINATION DATE OF INSURANCE Covered Person's Termination Date. A covered person's coverage under this policy ends on the earliest of: 1. The date this policy terminates; 2. The premium due date if premiums are not paid when due; 3. The effective date on which the covered person requests, in writing, that his or her coverage be terminated; 4. The effective date of any written notice of termination by us; or 5. The date the covered person ceases to be a member of any eligible class(es) of persons as described in the Classes of Eligible Persons section of the schedule of benefits. BSR 7000 (Ed. 01/15) Page 6 of 13 SECTION VII - DESCRIPTION OF BENEFITS The following provisions explain the benefits available under the policy. Please see the schedule of benefits for the applicability of these benefits on a class level. A. ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS If injury to the covered person results in any one of the covered losses specified below, within the incurral period shown in the schedule of benefits, we will pay the percentage of the principal sum shown below for that covered loss. The principal sum is shown in the schedule of benefits. If more than one covered loss is sustained by a covered person as a result of the same covered accident, only one amount, the largest, will be paid. Covered Loss Benefit Amount Life.............................................................. ................. .............................................. ....... 100% of the Principal Sum Two or more Members.................................................................. ......... ...,..... 100% of the Principal Sum OneMember .............................................. ...................................... ........---- ......... ...... 50% of the Principal Sum Thumb and Index Finger of the Same Hand..,..a................................................ ................ 25% of the Principal Sum When used in this benefit, the following terms mean:. Member means loss of hand or foot, loss of sight, loss of speech and loss of hearing. Loss of 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 one eye. Loss of speech means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means. Loss of hearing means total and permanent loss of hearing in both ears that is irrecoverable and cannot be corrected by any means. Loss of a thumb and index finger of the same hand means complete severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). Severance means the complete separation and dismemberment of the part from the body. B. ACCIDENT MEDICAL EXPENSE BENEFITS We will pay Accident Medical Expense Benefits for covered expenses that result directly, and from no other cause, from a covered accident. Accident Medical Expense Benefits are only payable: 1. For reasonable charges, incurred after the deductible has been met; 2. For medically necessary covered expenses that the covered person incurs; 3. For charges incurred within 52 weeks after the date of the covered accident; 4. Provided the first covered expense is incurred within 90 days after the date of the covered accident; and 5. Subject to the Deductibles, Coinsurance, Rates, Maximum Benefit Periods, Benefit Maximums and other terms or limits shown in the schedule of benefits. No benefits will be paid for any expenses incurred that are in excess of reasonable charges. Covered Expenses 1. Hospital Room and Board Expenses: the daily room rate when a covered person is hospital confined and general nursing care is provided and charged for by the hospital. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge. 2. Ancillary Hospital Expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines (excluding take home drugs) when hospital confined. BSR 7000 (Ed. 01/15) Page 7 of 13 3. Daily Intensive Care Unit Expenses: the daily room rate when a covered person is hospital confined in a bed in the intensive care unit and nursing services other than private duty nursing services. 4. Registered Nurse Services while a covered person is hospital confined; these services must be ordered by a physician. 5. Emergency Care (room and supplies) Expenses: incurred within 72 hours of an accident and including the attending physician's charges, X-rays, laboratory procedures, use of the emergency room and supplies. 6. Diagnostic x-rays, laboratory procedures and tests. 7. Free -Standing Ambulatory Surgical Center or Free -Standing Ambulatory Medical Center expenses. 8. Physician Non -Surgical Treatment/Examination Expenses (excluding medicines) including the physician's initial visit, each medically necessary follow-up visit and consultation visits when referred by the attending physician. 9. Physician's Surgical Expenses. 10. Anesthesiologist Expenses and administration of anesthesia. 11. Physiotherapy Expenses on an inpatient or outpatient basis limited to one visit per day (as shown in the schedule of benefits). Expenses include treatment and office visits connected with such treatment when prescribed by a physician, including diathermy, ultrasonic, whirlpool, or heat treatments, adjustments, manipulation, massage or any form of physical therapy. 12. Diagnostic Imaging Expenses including Magnetic Resonance Imaging (MRI) and CAT Scan. 13. Dental Expenses including dental x-rays for the repair or treatment of each injured tooth that is whole, sound and a natural tooth at the time of the covered accident. 14. Ambulance Expenses for transportation from the emergency site to the hospital. 15. Rental of durable medical equipment that: a. 'Is primarily and customarily used to serve a medical purpose; b. Can withstand repeated use; and c. Generally is not useful to a person in the absence of injury. No benefits will be paid for rental charges in excess of the purchase price, 16. Prescription Drug Expenses (for injuries only) prescribed by a physician and administered on an outpatient basis. 17. Medical Services and Supplies: expenses for blood and blood transfusions; oxygen and its administration. 18. Artificial limbs, eyes, or other prosthetic appliances for initial acquisition and fitting. We will not pay for repair or replacement of artificial limbs, eyes or other prosthetic appliances. SECTION VIII - SCOPE OF COVERAGE Full Excess Benefits. This policy is secondary coverage to all other policies. We will pay covered expenses only after the covered person satisfies any deductible and only when the covered expenses are in excess of amounts paid or payable under any other benefit plan. We pay benefits without regard to any coordination of benefits provisions in any other benefit plan. The amount from other benefit plans includes any amount to which the covered person is entitled, whether or not a claim is made for the benefits. Coordination with Medicare: Accident Medical Expense Benefits will be paid in compliance with the Medicare Secondary Payer Act (42 U.S.C. §1395y) and any other applicable law regulating the coordination of benefits of government health plans. We do not intend to shift to Medicare, Medicaid or any other governmental health plan with secondary payer status, the responsibility of primary coverage or payment for any injury for which benefits are payable under this policy. BSR 7000 (Ed. 01/15) Page 8 of 13 SECTION IX — EXCLUSIONS AND LIMITATIONS EXCLUSIONS We will not pay benefits for any loss or injury that is caused by, or results from: 1. Sickness, disease, mental infirmity, emotional or psychological trauma, or bacterial or viral infection, or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food; 2. Suicide, self-destruction, attempted suicide or self-destruction, or intentional self-inflicted injury, while sane or insane; 3. War or any act of war, whether declared or not; 4. Commission of, or attempt to commit, a felony, an assault, or other illegal activity; 5. Commission of or active participation in a riot, insurrection, or civil disturbance; 6. Medical or surgical treatment, diagnostic procedure, administration or anesthesia, or medical mishap or negligence, including malpractice; 7. The covered person being legally intoxicated as determined according to the laws of the jurisdiction in which the injury occurred; 8. The covered person being intoxicated or under the influence of any drugs or narcotics unless administered by or upon the advice of a physician; 9. Any poison, chemical compound, gas or fumes voluntarily taken, administered, absorbed, or inhaled by a covered person; 10. Any loss arising out of terrorism or terrorist acts; 11. Injury covered by workers' compensation, employer's liability laws, or similar occupational benefits, or while engaging in activity for monetary gain from sources other than the Policyholder; 12. A covered accident that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon our receipt of proof of service, we will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded, unless it extends beyond 31 days; 13. Travel in, flight in, boarding, or alighting from an aircraft or aerial device or any craft designed to fly above the Earth's surface; 14. Travel in any aircraft owned, leased, or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be "controlled" by the Policyholder if the aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year; 15. An accident that results in a cardiovascular accident or stroke caused solely and exclusively by exertion, as verified by a physician, while the covered person participates in a covered activity; 16. Aggravation, during a covered activity, of an injury the covered person suffered before participating in that covered activity, unless we receive a written medical release from the covered person's physician; 17. Participation in covered activities not sponsored by or under the supervision of the Policyholder; BSR 7000 (Ed. 01/15) Page 9 of 13 In addition to the exclusions above, we will not pay Accident Medical Expense Benefits for any loss, treatment, or services resulting from, or contributed to, by: 1. Pre-existing conditions occurring within the first 12 months of coverage (except as specifically provided by the policy); 2. Treatment by persons employed or retained by a Policyholder, or by any immediate family member or member of the covered person's household; 3. Pregnancy, childbirth, or miscarriage; 4. Elective abortion, an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed; 5. Mental and nervous disorders; 6. Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the policy); 7. Elective or cosmetic surgery, except for reconstructive surgery needed as the result of an injury; 8. Eyeglasses, contact lenses, hearing aids, wheelchairs, braces, appliances, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices (except as specifically provided in the policy; 9. Orthopedic appliances used mainly to protect an injury, so the covered person can participate in a covered activity; 10. Expenses for which the covered person would not be responsible for in the absence of this policy; 11. Expenses paid or payable under any automobile insurance policy without regard to fault; (This exclusion does not apply in any state where prohibited.) 12. Blood, blood plasma, or blood storage, except expenses by a hospital for processing or administration of blood; 13. Treatment of injuries that result over a period of time (such as blisters, tennis elbow, etc.), and that are a normal, foreseeable result of participation in the covered activity; 14. Treatment or service provided by a private duty nurse (except as specifically provided in the policy); 15. Replacement of artificial limbs, eyes, or other prosthetic appliances; 16. Routine physicals, check-ups, routine ob-gyn visits, pap smears, or wellness visits; 17. Overuse symptoms including, but not limited to, bursitis, tendonitis, shin splints, stress fractures, heat exhaustion, heat stroke, heat prostration, malfunctions of the heart, embolism, reinjures or the aggravation thereof, sprains, hernia, strains, muscle tears, or repetitive motion injury, except as specifically provided in the policy; 18. Expenses due to an aggravation or re -injury of a pre-existing condition (except as specifically provided in the policy); 19. Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration (except as specifically provided in the policy); 20. Repair, replacement, examinations for prescriptions, or the fitting of eyeglasses or contact lenses; 21. Medical expenses and disability for which the covered person is entitled to benefits under any Worker's Compensation Act; 22. Chiropractic care (except as specifically provided in the policy); 23. Expenses incurred that are in excess of reasonable charges, or expenses that are not medically necessary; or 24. Dental treatment necessitated by sickness, deterioration or disease, for cosmetic, preventive, diagnostic or orthodontic purposes, or by any reason other than an injury. LIMITATIONS Limitation. We will not provide coverage or pay benefits under this policy to the extent, and only to the extent, that we are prohibited from providing coverage or making payment by any type of travel restriction, trade restriction, economic sanction, or embargo imposed by the U.S. government. This limitation will not apply if the covered person has received a license from the U.S. government to engage in the prohibited activity, provided we receive a copy of the license. Aggregate Limit. The maximum amount payable under this policy may be reduced if more than one covered person suffers a loss as a result of the same covered accident, and if amounts are payable for those losses under one or more of the following benefits provided by this policy: Accidental Death, Accidental Dismemberment, and Paralysis Benefits. The maximum amount payable for all such losses for all covered persons under all those benefits combined will not exceed the amount shown as the Aggregate Limit in the schedule of benefits. If the combined maximum amount otherwise payable for all covered persons must be reduced to comply with this provision, the reduction will be taken by applying the same percentage of reduction to the individual maximum amount otherwise payable for each covered person for all such losses under all those benefits combined. BSR 7000 (Ed. 01 /15) Page 10 of 13 SECTION X - CLAIM PROVISIONS Notice of Claim. Written notice of claim must be given to us within 20 days after a covered person's loss, or as soon thereafter as reasonably possible. Notice must be given by or on behalf of the claimant to us, with information sufficient to identify the covered person. Claim Forms. We will send claim forms to the claimant upon receipt of a written notice of claim. If such forms are not sent within 15 days after the giving of notice, the claimant will be deemed to have met the proof of loss requirements upon submitting, within the time fixed in this policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. The notice should include the covered person's name, the Policyholder's name and the Policy Number. Proof of Loss. Written proof of loss must be furnished to us within 90 days after the date of the loss. If the loss is one for which this policy requires continuing eligibility for periodic benefit payments, subsequent written proofs of eligibility and of the loss must be furnished at such intervals as we may reasonably require. Failure to furnish such proofs within the time required neither invalidates nor reduces any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time proof is otherwise required. Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of a covered person will be made to the covered person's beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. If there is no named beneficiary or surviving beneficiary on record with Us, We will pay benefits in equal shares to the first surviving class of the following: (1) Spouse/Domestic Partner, (2) Children, (3) Parents, (4) Brothers and Sisters. If there are no survivors in any of these classes, We will pay the Covered Person's estate. Upon receipt of due written proof of loss, payments for all other losses will be made to (or on behalf of, if applicable) the covered person suffering the loss. If a covered person dies before all payments required under this policy have been made, then any remaining amount still payable will be paid to his or her beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee's property. If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made, at our option, to any relative by blood or connection by marriage of the payee, who, in our sole judgment, has assumed the custody and support of the minor or responsibility for the incompetent person's affairs. We may pay benefits directly to any hospital or person rendering covered services, unless the covered person requests otherwise in writing. Such request must be made no later than the time proof of loss is filed. Any payment we make in good faith fully discharges our liability to the extent of the payment made. Time of Payment of Claims. Benefits payable under this policy, other than for loss for which this policy provides for periodic payments, will be paid within 30 days after our receipt of due written proof of the loss. Subject to our receipt of due written proof of loss, all accrued benefits for loss for which this policy provides periodic payment will be paid at the expiration of each month during the continuance of the period for which we are liable and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of such proof. BSR 7000 (Ed. 01/15) Page 11 of 13 SECTION XI - GENERAL PROVISIONS Entire Contract; Changes. This policy, together with any schedules, riders, endorsements, amendments, applications, and enrollment forms, if any, make up the entire contract between the Policyholder and us. In the absence of fraud, all statements made by the Policyholder or any covered person will be considered representations and not warranties. No written statement made by a covered person will be used in any contest, unless a copy of the statement is furnished to the covered person or his or her beneficiary or personal representative. No change in this policy will be valid, until approved by an officer of Great American Insurance Company. Such approval must be noted on or attached to this policy in writing. No agent may change this policy or waive any of its provisions. Incontestability. The validity of this policy will not be contested after it has been in effect for 2 years from the Policy Effective Date, except as to nonpayment of premiums. Beneficiary Designation and Change. The covered person's designated beneficiary(ies) is (are) the person(s) so named by the covered person and on signed record with the Policyholder. A legally competent covered person over the age of majority may change his or her beneficiary designation at any time, unless an irrevocable designation has been made. The change may be executed, without the consent of the designated beneficiary(ies), by providing us or, if agreed upon in advance by us, the Policyholder, with a written request for change. When the request is received by us or, if agreed upon in advance by us, the Policyholder, whether the covered person is then living or not, the change of beneficiary will relate back to and take effect as of the date of execution of the written request, but will not apply to or prejudice us as respects any payment which may have been made prior to our receipt of the request. Physical Examination and Autopsy. We have the right, at our own expense, to examine the covered person, when and as often as may be reasonably required during the pendency. of a claim. We may also require an autopsy of the remains of any covered person where it is not prohibited by law. Legal Actions. No legal action for a claim can be brought against us until 60 days after receipt of proof of loss. No legal action for a claim can be brought against us more than three years after the time for giving proof of loss. Noncompliance With Policy Requirements. No express waiver by us of any requirement(s) of this policy will constitute a continuing waiver of such requirement(s). Any failure by us to insist upon compliance with any policy provision(s) will not operate as a waiver or amendment of that provision. Conformity With Statutes. Any provision of this policy which, on its effective date, is in conflict with the law of the jurisdiction in which the policy was delivered, is hereby amended to conform to the minimum requirements of such law. Clerical Error. Clerical error, whether by the Policyholder, the covered person or us in keeping records pertaining to this policy, will not: 1. Invalidate coverage otherwise validly in effect; or 2. Continue coverage otherwise validly terminated. Data Required. The Policyholder must maintain adequate records acceptable to us and provide any information required by us relating to this insurance, its premium, and any benefits claimed or paid hereunder. Audit. We will have the right to inspect and audit, at any reasonable time, all records and procedures of the Policyholder that may have a bearing on this insurance, its premium, and any benefits claimed or paid hereunder. Non -Duplication of Workers' Compensation Benefits. No benefits will be payable under this policy for any loss for which the covered person claims coverage under any workers' compensation, employers' liability, occupational disease or similar law. In the event a claim is made under any workers' compensation, employers' liability, occupational disease or similar law arising out of the same or substantially same accident or injury, the covered person must immediately reimburse us for all benefits paid in conjunction with that accident or injury. Right to Receive and Release Needed Information. We have the right to decide in our sole judgment what facts we need to administer this policy. We may get needed facts from, or give them to, any other organization or person. We need not tell, or get the consent of, any person to do this. Each person claiming benefits under this policy must give us any facts we need to determine coverage under this policy or determine the correct payment of a claim. BSR 7000 (Ed. 01/15) Page 12 of 13 Facility of Payment and Right of Recovery. If a payment made under another plan includes an amount that should have been paid under this policy, we may pay that amount to the organization making that payment. That amount will then be treated as though it were a benefit paid under this policy, and we will not have to pay that amount again. If the amount of the payments made by us is more than it should have paid under this policy, we may recover the excess from any person(s) to or for whom we have overpaid, including insurance companies or other organizations. Time Limit on Certain Defenses. After two years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by an applicant in any application for this policy will be used to void this policy or to deny a claim for loss incurred or disability, as defined in this policy, commencing after the expiration of such two year period. No claim for loss incurred or disability, as defined in this policy, commencing after two years from the date of issue of this policy will be reduced or denied on the ground that a condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy. Certificates Of Insurance. Where it is required by law, or upon the request of the Policyholder, we will make available certificates outlining the insurance coverage, and to whom benefits are payable under the policy. Subrogation. To the extent we make a payment under this policy and the person to whom or for whose benefit payment has been made has any right to recover from anyone liable for the covered loss, we may assume the rights of the covered person and/or his or her designated beneficiary. We will be reimbursed for any payments made to or on behalf of the covered person and/or the designated beneficiary, regardless of whether or not the covered person or person to whom payment has been made has been made whole. The covered person and/or his or her designated beneficiary will do everything necessary to transfer those rights to us, will do nothing to prejudice those rights and agrees to assist us in preserving our subrogation and reimbursement rights. The covered person or designated beneficiary must reimburse us for any payments we make under this policy, to the extent that covered person or designated beneficiary receives payment from any party for the same covered loss. Assignment. This policy is non -assignable. A covered person may assign all of his or her rights, privileges and benefits under this policy. We are not bound by an assignment, until we receive a signed copy. We are not responsible for the validity of assignments. The assignee only takes such rights as the assignor possessed and such rights are subject to state and federal laws and the terms of this policy. Any payment made in good faith will relieve us or our liability under the policy. BSR 7000 (Ed. 01 /15) Page 13 of 13 Administrative Offices 301 E 4th Street GREX%V1E'PJ(A 1, Cincinnati OH 45202-4201 INSURANCE GROUP 5133695000ph BSR 1021 (Ed.01/15) GREAT AMERICAN INSURANCE COMPANY CALIFORNIA AMENDATORY ENDORSEMENT This rider is attached to and made part of the policy as of the Effective Date shown above. If no Effective Date is shown, this rider takes effect as of the Policy Effective Date shown on the schedule of benefits. It is subject to all the provisions, limitations, and exclusions of the policy, except as they are otherwise specifically modified by this rider. It applies only with respect to a loss that occurs on or after the Policy Effective Date and prior to the termination of the policy. This rider terminates at the same time as the policy. BLANKET ACCIDENT INSURANCE POLICY — BSR 7000 is amended as follows: SECTION I — DEFINITIONS, is amended as follows: 1. The definition of Covered Accident is hereby deleted and replaced with the following: Covered Accident means an accident that occurs while coverage is in effect for a covered person resulting in a covered loss or injury under the policy for which benefits are payable. The covered person must be participating in a covered activity or specified hazard, as identified in the schedule of benefits, when the accident occurs. 2. The definition of Covered Person is hereby deleted and replaced with the following: Covered Person means an eligible person, who enrolls for coverage, if required, and for whom the required premium is paid, subject to the Grace Period provision. 3. The definition of Injury is hereby deleted and replaced with the following: Injury means bodily injury sustained by a covered person caused by a covered accident that: 1. Occurs while this policy is in effect as to the person whose injury is the basis of claim; 2. Occurs while the covered person is participating in a covered activity; 3. Occurs under the circumstances described in a hazard applicable to that person; and 4. Results in a covered loss under a benefit applicable to such hazard. See the schedule of benefits for applicability of hazards and benefits. All injuries sustained by one covered person in any one covered accident, including all related conditions and recurrent symptoms of the injuries are considered a single injury. 4. The definition of Spouse is hereby deleted and replaced with the following: Spouse means an adult person with whom the covered person enters into a marriage, civil union, or comparable relationship in a state or nation in which the marriage, civil union or comparable relationship is sanctioned by law and legally valid at the time it is entered into by the parties. Spouse also includes domestic partners. SECTION VI — DESCRIPTION OF BENEFITS is amended as follows: 1. The lead-in to the Accident Medical Expense Benefit is hereby deleted and replaced with the following: We will pay Accident Medical Expense Benefits for covered expenses that result from a covered accident. BSR 1021 (Ed. 01/15) Page 1 of 3 SECTION IX — EXCLUSIONS AND LIMITATIONS is amended as follows: 1. The following exclusion 2. under the general Exclusions is hereby deleted and replaced with the following: 2. Suicide, self-destruction, attempted suicide or self-destruction, or self-inflicted injury, while sane or insane. 2. The following exclusion 4. under the general Exclusions is hereby deleted and replaced with the following: 4. Commission of, or attempt to commit, a felony or being engaged in other illegal activity. 3. The following exclusion 18. under the general Exclusions is hereby deleted and replaced with the following: 18. An accident that results in a cardiovascular accident or stroke caused solely and exclusively by exertion, as verified by a physician, while the covered person participates in a covered activity. SECTION X - CLAIM PROVISIONS, is amended as follows: 1. The Payment of Claims provision is hereby deleted and replaced with the following: Payment of Claims. Upon receipt of due written proof of death, payment for loss of life of a covered person will be made to the covered person's beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. If there is no named beneficiary or surviving beneficiary on record with Us, We will pay benefits in equal shares to the first surviving class of the following: (1) Spouse/Domestic Partner, (2) Children, (3) Parents, (4) Brothers and Sisters. If there are no survivors in any of these classes, We will pay the Covered Person's estate. Upon receipt of due written proof of loss, payments for all other losses will be made to (or on behalf of, if applicable) the covered person suffering the loss. If a covered person dies before all payments required under this policy have been made, then any remaining amount still payable will be paid to his or her beneficiary as described in the Beneficiary Designation and Change provision of the General Provisions section. If any payee is a minor or is not competent to give a valid release for the payment, the payment will be made to the legal guardian of the payee's property. If the payee has no legal guardian for his or her property, a payment not exceeding $1,000 may be made to any relative by blood or connection by marriage of the payee, who, in our sole judgment, has assumed the custody and support of the minor or responsibility for the incompetent person's affairs. We may pay benefits directly to any hospital or person rendering covered services, unless the covered person requests otherwise in writing. Such request must be made no later than the time proof of loss is filed. Any payment we make in good faith fully discharges our liability to the extent of the payment made. 2. The Time of Payment of Claims provision is hereby deleted and replaced with the following: Time of Payment of Claims. Benefits payable under this policy, other than for death or loss for which this policy provides for periodic payments, will be paid immediately upon our receipt of due written proof of the loss. Benefits payable for accidental death will be paid within 30 days of receipt of proof of death. If the benefit for accidental death is not paid within that time, interest will accrue at the rate of 6% per annum from the date of receipt of proof of death, until the date the benefit is paid. Subject to our receipt of due written proof of loss, all accrued benefits for loss for which this policy provides periodic payment will be paid at the expiration of each month during the continuance of the period for which we are liable and any balance remaining unpaid upon termination of liability will be paid immediately upon receipt of such proof. BSR 1021 (Ed. 01/15) Page 2 of 3 SECTION XI - GENERAL PROVISIONS, is amended as follows: 1. The Entire Contract; Changes provision is hereby deleted and replaced with the following: Entire Contract; Changes. This policy, together with any schedules, riders, endorsements, amendments, applications, and enrollment forms, if any, make up the entire contract between the Policyholder and us. In the absence of fraud, all statements made by the Policyholder or any covered person will be considered representations and not warranties. No written statement made by a covered person will be used in any contest, unless a copy of the statement is furnished to the covered person or his or her beneficiary or personal representative. No change in this policy will be valid, until approved by an executive officer of Great American Insurance Company. Such approval must be noted on or attached to this policy in writing. No agent may change this policy or waive any of its provisions. 2. The Incontestability provision is hereby deleted and replaced with the following: Incontestability. After 3 years from the date of issue of the policy, no misstatement of the Policyholder, except a fraudulent misstatement made in the application shall be used to void the policy. After 3 years from the effective date of the coverage with respect to which any claim is made, no misstatement of any covered person under the policy, except a fraudulent misstatement, made in an enrollment form under the policy, shall be used to deny a claim for loss incurred or disability commencing after expiration of such 3 years. 3. The Physical Examination and Autopsy provision is hereby deleted and replaced with the following: Physical Examination and Autopsy. We have the right, at our own expense, to examine the person of any individual whose injury or sickness is the basis of a claim, when and as often as may be reasonably required during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law. 4. The Legal Actions provision is hereby deleted and replaced with the following: Legal Actions. No legal action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. 5. The Non -Duplication of Workers' Compensation Benefits provision is hereby deleted and replaced with the following: Non -Duplication of Workers' Compensation Benefits. No benefits will be payable under this policy for any loss for which the covered person claims coverage under any workers' compensation, employers' liability, occupational disease or similar law. In the event a claim is made under any workers' compensation, employers liability, occupational disease or similar law as a direct result of the same or substantially same accident or injury, the covered person must immediately reimburse us for all benefits paid in conjunction with that accident or injury. 6. The Subrogation provision is hereby deleted: Subrogation. To the extent we make a payment under this policy and the person to whom or for whose benefit payment has been made has any right to recover from anyone liable for the covered loss, we may assume the rights of the covered person and/or his or her designated beneficiary. We will be reimbursed for any payments made to or on behalf of the covered person and/or the designated beneficiary, regardless of whether or not the covered person or person to whom payment has been made has been made whole. The covered person and/or his or her designated beneficiary will do everything necessary to transfer those rights to us, will do nothing to prejudice those rights and agrees to assist us in preserving our subrogation and reimbursement rights. The covered person or designated beneficiary must reimburse us for any payments we make under this policy, to the extent that covered person or designated beneficiary receives payment from any party for the same covered loss. This rider is made a part of the Policy to which it is attached. All other terms and conditions of the Policy remain unchanged. BSR 1021 (Ed. 01/15) Page 3 of 3 Administrative Offices CrREAT AMEwCAN 301 E 4th Street Cincinnati OH 45202-4201 INSURANCE GROUP 5133695000ph IL 72 68 (Ed. 09 09) In Witness Clause In Witness Whereof, we have caused this Policy to be executed and attested, and, if required by state law, this Policy shall not be valid unless countersigned by our authorized representative. President Secretary Copyright Great American Insurance Co., 2009 IL 72 68 (Ed. 09/09) 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: L_) 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 # (V) 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 t o e provision, the agree will automatically become void. 3/26/2025 Signature of Applicant Date Print Name Grace Maxwell Agreement for Dated. Reviewed by: