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Amateur Teams, Leagues & Associations Add / Delete Form For use with policies with EFFECTIVE date of 03/01/2014 – 02/28/2015 ORGANIZATION INFORMATION

Named Insured:

Contact Name: Mailing Address: City: State: Zip: Phone: Cell: Fax #: Email:

CHANGE REQUEST SECTION • COSTS ARE 100% FULLY EARNED AND NON-REFUNDABLE ONCE COVERAGE BEGINS. Any request for deletions are subject to underwriting approval based the effective date of the policy. By requesting deletion of participants, you are certifying that these participants have not participated in try-outs, practiced or played during this policy period. • Refer to the rate chart on the following page to complete the section below. HIGHER LIMITS AVAILABLE- For liability limits of $3,000,000, $4,000,000, and $5,000,000 please contact us for a quote. • Choose the same coverage option that you originally applied for. ORIGINAL LIMITS: Class  Class A  Class B / Coverage Option (from rate chart)  Opt 1  Opt 2  Opt 3 AGE ADD # of: DELETE # of: Premium Per Total SPORT X = GROUP Participants Participants Participant Premium X $ = $ X $ = $ X $ = $ X $ = $ X $ = $ X $ = $ Total Amount of Premium Due (or Credit) If additional premium is due, please see payment options below. = $ If a credit / refund is owed to you, Sadler & Company will send you a refund check. Does your operation involve tackle or contact ?  Yes  No If yes, Do you maintain a system for your tackle/contact 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?  Yes  No Regardless of general liability occurrence limits purchased, legal liability to participants for coverage for tackle and contact football will be limited to $1,000,000 per occurrence.

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.

Remit this completed form and corresponding premium payment to our office via Fax: 803-256-4017 / Email: [email protected] / Mail

PO Box 5866, Columbia, SC 29250-5866 Phone (800)622-7370 Fax (803)256-4017

How do you wish to pay the additional premium? These changes will only take effect once all information AND full payment is received.  Check/Copy of Check Enclosed made payable to Sadler & Company  Please send a credit card link to the email address above. (You will receive a link within 1-2 Business Days)

CLASS A SPORTS CLASS B SPORTS Box Disabled Sports Drill Team (Age 19 Racquetball Track & Field /T- & Under) Roller Skating (Excluding Javelin / Rope Skipping Hammer) Ice Baton Twirling Running (5k or 10k) Frisbee In-line Hockey Billiards Figure Skating Scooter Hockey Umpire/Referee In-line Skating (speed) Ball Flag & Soccer (age 19 & Associations Lacrosse (age 20 & over) Football under) Power Lifting (age 20 & over) Cheerleading (Age Frisbee/Frisbee Water Hockey (age (inline) 19 & Under) Golf Speed Skating (ice) 19 & under) Soccer (age 20 & over) (Team) Squash Water (age 19 Water Hockey (age 20 & over) Croquet Stick Hockey & under) (age 20 & over) Cross Country Ski Lacrosse (Age 19 & Weightlifting (age Weightlifting (age 20 & over) Under) Tackle & Contact 19 & under) (age 20 & over) Football Deck/Floor/Street Power Lifting (Age Wrestling (age 19 & (age 19 & under) Hockey 19 & Under) under) Team Handball Pickleball Roller Hockey (quad)

PROGRAM RATES AND MINIMUM PREMIUMS CLASS A SPORTS Option 1 - $1,000,000 Limit Option 2 - $2,000,000 Limit Rates (per participant, all sports, all ages) $ 3.57 $ 5.36 Minimum Premiums $ 300.00 $ 400.00

CLASS B SPORTS – Rates (per participant, per sport) Option 1 Option 2 Option 3 Options $1,000,000 CGL Limit $2,000,000 CGL Limit $2,000,000 CGL Limit $25,000 Medical Payment $100,000 Medical Payment $250,000 Medical Payment 12 & 13-15 16-19 20 & 12 & 13-15 16-19 20 & 12 & 13-15 16-19 20 & Ages Under Over Under Over Under Over Baseball, t-ball $ 6.11 $10.03 $15.87 $28.81 $ 8.59 $13.87 $18.45 $36.98 $ 9.26 $15.65 $21.09 $43.34 Basketball, Deck/floor/field/, Racquetball, Roller hockey (quad), $ 5.89 $ 7.00 $14.39 $19.31 $ 8.30 $ 9.93 $18.90 $25.07 $ 8.96 $10.87 $21.66 $29.40 Ultimate Frisbee, Flag & touch football, team handball Baton twirling, Golf, Frisbee, Kickball, Swimming, Tennis, $ 5.62 $ 5.62 $ 5.62 $ 5.62 $ 7.94 $ 7.94 $ 7.94 $ 7.94 $ 8.91 $ 8.91 $ 8.91 $ 8.91 Track & Field, Pickleball Cheerleading, Drill $ 6.26 $ 7.54 $16.12 N/A $ 8.77 $10.66 $21.07 N/A $ 9.53 $11.75 $24.27 N/A team Cricket, Squash $ 5.76 $ 9.14 $14.18 $25.33 $ 8.42 $12.69 $16.65 $32.62 $ 8.72 $14.23 $18.92 $38.10 Disabled Sports $ 5.89 $ 7.00 $14.39 $19.31 $ 8.30 $ 9.93 $18.90 $25.07 $ 8.96 $10.87 $21.66 $29.40 Lacrosse, Water polo Class A Class A Class A $ 7.17 $ 8.20 $ 9.86 $3.57 $10.29 $12.03 $13.27 $5.36 $10.87 $12.76 $14.89 $5.36 Soccer Class A Class A Class A $ 7.74 $ 8.94 $10.87 $3.57 $11.08 $13.10 $14.54 $5.36 $11.75 $13.95 $16.42 $5.36 Softball $ 5.79 $ 6.88 $15.87 $28.81 $ 8.15 $ 9.74 $18.45 $36.98 $ 8.78 $10.66 $21.09 $43.34 Tackle and contact $21.48 $38.61 $51.85 N/A $28.65 $52.11 $67.32 N/A $32.32 $60.43 $78.69 N/A football Umpire & referee $ 8.45 $ 8.45 $ 8.45 $ 8.45 $11.31 $11.31 $11.31 $11.31 $12.80 $12.80 $12.80 $12.80 associations Volleyball, Archery $ 5.95 $ 5.95 $ 5.95 $ 5.95 $ 8.36 $ 8.36 $ 8.36 $ 8.36 $ 9.47 $ 9.47 $ 9.47 $ 9.47 teams Wrestling Class A Class A Class A $16.23 $16.23 $16.23 $3.57 $21.74 $21.74 $21.74 $5.36 $25.05 $25.05 $25.05 $5.36

SEXUAL ABUSE & MOLESTATION LIABILITY PREMIUM 1. If you currently have Sexual Abuse or Molestation Liability Coverage in place, Sadler & Company will compute the additional premium due and send a payment link/email with the additional premium required. This premium must be paid prior to approving the addition of the camps. 2. If you would like to add this coverage to your policy mid-term, please contact us for additional information and the proper form to complete for review and approval. If Applicable - SUBMITTING AGENT: NOTE: Agents do not have authority to bind coverage, issue binders or certificates of insurance on behalf of this program. Agency Name: Contact Person: Mailing Address: City: State: Zip: Email: Phone: Fax:

FOR SADLER OFFICE USE ONLY Minimum Premium Review CSR: Refund/Balance Due $ Sexual Abuse/Molestation Add to Current / Due $ Credit Card Link Sent CSR: Date: Amount: $