Enrollment Form for Club/Intramural Catastrophic Insurance Underwritten by Mutual of Omaha Insurance Company; 3300 Mutual of Omaha Plaza; Omaha, NE 68175

1. General Information Name of Institution Full Legal Name Address Street City State Zip Contracting Official Name Title Phone Fax E-mail Address

2. Premium (See back side of form for sports list and risk categories)

A. Club Sports Complete the General Information under Section 1. Fill in the total number of Club Sports participants (female and male). Please be sure to look through all sections and categories as the Club Sports listed in the census section will be included in the quote.

Total Club Premium $

B. Intramural Sports Complete the General Information under Section 1. Fill in the total number of Intramural Sports participants (female and male). Please be sure to look through all sections and categories as the Intramural Sports listed in the census section will be included in the quote.

Total Intramural Sport Premium $

Grand Total Club and Intramural Sport Premium $ (There is a nonrefundable minimum premium of $650.00)

Make premium check payable to Relation and mail payment along with this completed form to one of the following offices: Overland Park: Salt Lake City: P.O. Box 25936 2180 South, 1300 East, Suite 520 Overland Park, KS 66225 Salt Lake City, UT 84106 1-800-955-1991, ext. 5614 1-800-955-1991, ext. 2627 Attn: Janice Briggs Attn: Carol Malouf

3. Term of Coverage It is understood that the effective date of coverage under this program will be August 1, or the date this form and the premium are received and accepted by the Company, whichever is later. Coverage expires one year from the effective date. By Date Signature of Contracting Official

Licensed Agent’s Signature License Number Date

MUGC9567_IN1 See Brochure for Additional Information 2018 – Generic Club/Intramural Cat (10 Year) CLUB/INTRAMURAL SPORTS AND RISK CATEGORIES (Please indicate the # of Participants per sport within each category) Name of Institution

Low Risk Category Medium Risk Category # of # of # of Club # of Club Sports Intramural Sports Intramural Sport Sport Sport Sport Participants Participants Participants Participants Aerobics Archery Cheerleading Badminton Wall Band Cycling Billiards Equestrian Figure Skating Canoe/Kayak (Flag or ) Log Rolling Cross Country Running Marathon Cross Country Skiing Paintball Quidditch Dance Scuba Disc Golf Swimming E-games Track & Field Fencing Triathlon Fishing Water Golf Riflery Rowing/Crew Sailing Soccer Squash Student Managers Student Trainers Tennis (Table or Court) Frisbee Walking Weightlifting Wiffle Ball Yoga Zumba

TOTAL TOTAL

Relation is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Mutual of Omaha Insurance Company. CLUB/INTRAMURAL SPORTS AND RISK CATEGORIES (Please indicate the # of Participants per sport within each category) Name of Institution

High Risk Category Very High Risk Category # of Club # of # of Club # of Sport Sports Intramural Sport Sports Intramural Participants Sport Participants Sport Participants Participants Climbing Boxing Diving Football (Tackle) Field Gymnastics Judo/Karate/Martial Arts Polo Outdoor Adventure Rodeo Rugby Skiing Wrestling

TOTAL TOTAL

Relation is an independent licensed insurance agency and is authorized to sell this student accident insurance on behalf of Mutual of Omaha Insurance Company.