HomeMy WebLinkAboutRexburg Track Club Cross Country Meet vs. Idaho Falls voc-print_php.pdf Amateur Teams / Leagues Online Application
Verification of Coverage
Application Receipt Date / Time: 05/16/2020 07:09:40 PM - entered by Customer
I. GENERAL INFORMATION
Application ID: 292742
Application Status: Complete
Name of Organization: Rexburg Track Club
Doing Business As:
Type of Organization: league_club
Form of Business: Corporation
Client type: previous
Contact's Name: Doug Stutz
Primary Location Address: 162 K Street
Address 2:
City: Rexburg
State: ID
County:
Postal / Zip Code: 83440-1438
Primary Phone: (208) 403-8471
Secondary Phone: (208) 496-7431
Fax:
Email Address: rexburgstutz@gmail.com
Website:
Alternate Contact Name:
Alternate Phone:
Alternate Email:
How did you find out about Sadler & Company: Already doing business with Sadler
Why Renew:
Do your Property Owners or Sponsors require a Certificate Of Insurance? No
Are you seeking coverage for all participants within your organization? Yes
Do any of your teams include both youth athletes (Class B sports) and adult athletes (Class A sports) participating together on the same team?
No
Online Agreement and Warranty Statement accepted? Yes
Are you responsible for the ownership, operation or maintenance of a facility or field? No
Are you a municipality or a park and recreation division? No
Do you meet the requirements by not answering Yes to any of the following? Is there any form of player compensation or prize money awarded
for participation?, Are you a school sanctioned sports team or league?,>Are you a Gymnastics, martial arts, cheer or dance studio?, Are any of
your activities held on private residential property?, Does the named insured owns or operates any pools?, Is a member of any of the following:
American Amateur Baseball Congress, American Youth Football, Babe Ruth/ Cal Ripken Baseball, Babe Ruth Softball, Dixie Boys Baseball, Dixie
Softball, Dixie Youth Baseball, Pop Warner, US Youth Soccer Association, Soccer Association for Youth, USA (SAY Soccer), World Adult Kickball
Association (WAKA.)? Yes
If you suspect an athlete has a concussion, do you have a plan that includes:
Immediately removing the athlete from play or practice Yes
Keeping the athlete out of play or practice until they provide written Yes
Does your operation involve tackle or contact flag football / Flex Football? No
If yes, Do you maintain a system for your tackle/ contact flag football / Flex Football activities that includes communication (in written or
electronic form) of education materials to participants, parents and coaches about the nature of risk of concussions, including but not
limited to information such as: focusing on prevention and preparedness to keep athletes safe; understanding concussions and
potential consequences of the injury; recognizing concussion symptoms and how to respond; and learning about steps for returning to
play after a suspected concussion? No
Note: The Center for Disease Control and Prevention offers free information, as well as a free online concussion training course on their website:
www.cdc.gov/ concussion/ HeadsUp/ youth.
Notes:
Organization Affiliation: Other
Exclusions: The following exclusions are contained in the commercial general liability coverage provided by this program: 24- hour premises
liability (unless optional coverage is purchased for sports fields); Abuse, molestation, harassment or sexual conduct (unless optional coverage
is purchased); Aircraft/ hot air balloon; Airport; Amusement devices (The ownership, operation, maintenance or use of: any mechanical or non-
mechanical ride, slide, or water slide, any inflatable recreational device, any bungee operation or equipment, any vertical device or equipment
used for climbing- either permanently affixed or temporarily erected, or dunk tank. Amusement devices do not include any video or computer
games or any device that is specifically designed for the training or instruction of the activity for which you are enrolled.); Animals (injury or
death to, or injury, death or property damage caused by any animal owned, rented or hired by you); Asbestos; Athletic or sports participants in:
Box lacrosse, Broomball, Diving, Dodgeball, Gymnastics, Hurling, Ice hockey, Inline hockey, Inline skating (speed), Judo, Karate, Lacrosse
(age 20 & over), Martial arts, Ringette, Roller hockey (inline), Taekwondo, Takraw, Umpire/ Referee Association for Class A Sports, Water
hockey (age 20 & over), Water polo (age 20 & over), Weightlifting (age 20 & over), Wrestling (age 20 & over); Babysitting/ child care services;
Carnivals/ festivals; Cheer and dance studios; Commercial general liability standard exclusions (CG0001 04/13 edition); Cryogenic chambers /
therapy; Concerts; Employment- related practices; Events involving gambling (eg: bingo, casino nights, poker, Texas hold'em tournaments);
Events where alcohol is served; Fireworks; Fungi or bacteria; Gymnastics studios; Haunted attractions; Intercollegiate & Interscholastic teams,
leagues and associations; Lead; Martial arts studios; Non- rostered participants at tournaments hosted by the enrolled member (unless optional
coverage is purchased); Nuclear energy liability; Operation, ownership or management of any athletic facility or field, other than while being
used for covered activities; Operations of independent concessionaires/ vendors in conjunction with your organization; Performers; Rodeos;
Saddle animals; Snowmobile; Sports events/ activities involving participants in sports other than those reported and for whom premium has
been paid; Transportation of athletes/ participants; Violation of statutes that govern e- mails, faxes, phone- calls or other methods of sending
material or information. Those operations listed as ineligible: Adventure races, Aerobic exercise, Bandy, Biathlon, BMX/ stunt cycling, Boating
activities/ sports, Bobsled, Body boarding, Boxing, Canoe, Cheerleading (age 20 & over), Climbing, Cycling, Dance (20 & over), Drill team/
majorette (age 20 & over), Equestrian, Fitness - aerobics and exercise, Hammer throw, Hang gliding, Hostelling, Inline (extreme/ stunt/
aggressive/ free- style) skating, Jai alai, Javelin, Kayaking, Kite surfing, Luge (street), Marathon, Mixed martial arts; Modern pentathlon,
Mountain biking and/ or hiking, Mountain boarding, Open water fishing, Open water activities/ sports, Orienteering, Outrigging, Parachute,
Parasailing, Physical fitness, Physique (pose) performance, Polo (horse), Rafting, Rodeo, Roller derby, Rowing/ Crew, Rugby, Sailing, Scuba
diving, Shooting sports, Skateboarding, Skiing (snow or water), Sky diving, Sky surfing, Sled dog racing, Snorkeling, Snow boarding, Snow
surfing, Soccer (age 20 & over), Sports parachuting, Strength and conditioning, Streetball, Surfing (including boogie boards), Tackle and
contact football (age 20 & over), Trampoline, Trapeze, Triathlon, Unicycling, Wake boarding, Wind surfing, Yachting
II. MEDICAL PAYMENTS TO PARTICIPANTS / GENERAL LIABILITY INSURANCE
Nationwide Mutual Insurance Company
Policy Number 6B RPG 72586
Sadler Sports: Amateur Teams / Leagues Insurance Plan
Nationwide Mutual Insurance Company
Policy Number 6B RPG 72586
Effective Date 12:01AM ET 06/01/2020
Expiration Date 12:01AM ET 06/01/2021
COVERAGE EFFECTIVE DATE: Coverage begins the exact time and date that this electronic application and internet check is received at
Sadler & Company or a future effective date if requested, whichever is later and continues for one full year from the effective date.
Limits $25,000 Medical Payments to Participants / $1,000,000 General
Liability
Medical Payments to Participants
Deductible $100.00
Medical Payments to Participants Plan Full Excess
NOTE:
Class C - High Risk Brain Injury Sports - For Deck/ Floor/ Street Hockey, Field Hockey, Flex Football (age 19 & under), Roller Hockey
(quad), Cheerleading (age 19 & under); Lacrosse (age 19 & under); Tackle and contact football (age 19 & under), Soccer (age 19 &
under), Water Hockey (age 19 & under),Wrestling (age 19 & under), and Umpire/ Referee Associations for the above High Risk
Concussion Sports, Limited Coverage for "Brain Injury" endorsement applies- Brain Injury Limit: $1,000,000 occurrence/ $1,000,000
aggregate; Brain Injury Loss Adjustment Expense Limit: $1,000,000 occurrence/ $1,000,000 aggregate. "Brain Injury" means concussion,
chronic traumatic encephalopathy, or any other injury to the brain and any symptoms, conditions, disorders and diseases, including death,
resulting therefrom but only if such injury occurs as a result of specific events occurring during the policy period.
Sports / Participants
Sports Age Groups # of Participants Totals
Track and Field (Excluding Javelin & Hammer)12 & Under 115 $661.25
($5.75 per participant)
Track and Field (Excluding Javelin & Hammer)13-15 27 $155.25
($5.75 per participant)
Totals $816.50
($816.5 min. premium)
Limits (minimum premium charges may apply)Charges
$25,000 Medical Payments to Participants / $1,000,000 General Liability $816.50
24hr Premises Liability Coverage
(Not Covered Unless Premium Accepted - Subject to Underwriting Approval)$0.00
Additional Coverage: Directors & Officers Liability Not Covered
State Surplus Lines Tax/ Surcharge $0.00
Additional Coverage: Crime Not Covered
State Surplus Lines Tax/ Surcharge $0.00
$0 Additional Coverage: Equipment Not Covered
State Surplus Lines Tax/ Surcharge $0.00
Risk Purchasing Group Membership Fee (required)$15.00
TOTAL CHARGES: $831.50
III. 24HR PREMISES LIABILITY COVERAGE
Do you meet the requirements by not falling under any of the following? No
You are a school sanctioned sports team or league. | You are a gymnastics, martial arts, cheer or dance studio or gym. | You are a municipality or a
park and recreation division. | Your organization has activities held on private residential property. | You own, operate or maintain a pool/ pool on
the outdoor premises for which you are applying for this coverage.
Number of Fields: 0
Number of Acres for Athletic Fields: 0
Location of the fields
Primary Location Address:
Address 2:
City:
State:
Postal / Zip Code:
IV. CERTIFICATES OF INSURANCE
V. ADDITIONAL COVERAGES
Additional Coverages are effective only upon final underwriting and acceptance by the carrier. If effective, all Additional Coverages expire one
year after effective date.
Directors & Officers Liability - NOT APPLIED FOR
Crime Insurance - NOT APPLIED FOR
Sadler Sports: Amateur Teams / Leagues Insurance Plan
Equipment Coverage - NOT APPLIED FOR
Summary of Declined Additional Coverages
VI. POLICY PERIOD CHANGES
This online enrollment provided the option for the organization to select General Liability/ Medical Payments, Directors and Office, Crime, Inland
Marine, Sexual Abuse & Molestation, Hosted Tournament Coverage and Premises Liability. However, Sadler offers other types of insurance
policies that are not available on this online enrollment such as Workers' Compensation, Excess Liability, Property (building and contents),
Event Cancellation, Cyber Risk, Business Auto, Professional Liability, etc. If I am interested in a quote for these other types of policies, I will
need to inform Sadler in writing, sport3@sadlersports.com.
Sadler & Company, Inc. * P.O. Box 5866 * Columbia, SC 29250-5866
Phone: 1-800-622-7370 * Fax: (803) 256-4017 * Email: amateur@sadlersports.com
Sadler Sports: Amateur Teams / Leagues Insurance Plan