Amateur Sports

Print or AMATEUR SPORTS Accident Insurance Policy Application type only which, upon acceptance and approval by Nationwide Life Insurance Company—Columbus, Ohio 43216, will become a part of Sports Accident Insurance Policy number 402– Office Use Only

Application for Sport: ______

1. Name of Plan Sponsor ______Group’s Name Address ______Street City State Zip County 2.Policy Term: The policy term starts at 12:01 a.m. on ______/ / which is the effective date and ends at 12:01 a.m. on ______/ / _ which is the renewal date. 3. Team Name(s) and Age Class(es) (for example, 4.Maximum Benefit Amounts ages 9 & under, 10-12, 13-15, 16-18 or 19 & over) Benefit Provisions Maximum Team Name Age Class (Check Medical Expense Plan Desired) Benefit Amount 1. A. Death and Specific osL s (Face Amount) $ 2. B. Medical Expense: Primary Plan, or Excess Plan 3. Deductible $ 4. Maximum Amount $ 5. 6. NOTE: If additional space is required, use a separate sheet. 5.Premium Rates Gross Rate per Discount of % for Net Rate per Number of Total Premium Age Class Player Insuring Teams Player Players Due 9 & Under $ - $ =$ x =$ 10-12 $ - $ =$ x =$ 13-15 $ - $ =$ x =$ 16-18 $ - $ =$ x =$ 19 & Over $ - $ =$ x =$ Total premium due subject to a minimum of: $225 if the medical expense PRIMARY plan has been elected and $175 if the medical expense EXCESS plan has been elected. $

6. It is understood and agreed that: (a) premium will be paid for all team players (participants); (b) all eligible persons will be insured; and (c) the premium will be paid entirely by the plan sponsor with no contribution made by the eligible persons toward the cost of the insurance. (NY) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. By sending your check to Nationwide Life Insurance Company (“Nationwide”), you give your consent to Nationwide to authorize our financial institution to convert your check into an electronic fund transfer. Please be aware that your bank account may be debited as soon as the same day we receive your payment and you will not receive a canceled check. For authorized checking account withdrawal (also called Automated Clearing House or “ACH”) call 844-203-2691. There are no premium refunds after a one (1) month policy term.

By signing below, you agree that you have read all of the Fraud Warnings provided with this application.

______Previous Policy Number Signature of Applicant ______Date Printed Name and Title of Applicant ______Appointed Agent’s Signature and Number Address of Applicant ______Appointed Agent’s Phone Number Applicant’s Phone Number ______Appointed Agent’s E-mail Address Applicant’s E-mail Address GR–9040-1A3) (Office Use) Check box if no agent was used. wide

Note: This brochure is available in DC, PR, VI, and all 50 states. Special rates of up to 80% higher apply to all public schools (private tion and religious schools use the rates shown in this brochure) – contact us for public school rates at 844-203-2691.

– 3 – 16 Na © 20 3 SHC-0145AO (01/16) Medical Expense Benefit Death and Specific osL s Benefit If, as a result of injury, an insured incurs covered expenses If, as a result of injury, an insured dies or suffers a specific starting within 90 days from the date of the accident loss within one year from the date of the accident causing causing the injury, we will pay, less the deductible (if any) the injury, we will pay a benefit as specified below: (the shown in the application and not to exceed the overall one year limit does not apply to the loss of life benefit in a maximum benefit amount, all oc vered expenses incurred PA or WV contract.) within 3 years from such date. Specific osL s % of Face Amount Covered expenses mean the reasonable and customary charges for local (“local” not applicable in a CT contract) Each Arm 75% professional ambulance service to or from a hospital and/ Each Leg 75% or surgical center as well as the following reasonable and customary charges for treatment, services and supplies Each Hand 50% provided or prescribed by a doctor: Each Foot 50% (1) hospital or surgical center care; Sight of Each Eye 50% (2) medical treatment; Speech 50% (3) nursing care provided by a licensed nurse; Hearing of Each Ear 25% (4) X-rays and lab exams; Thumb and Index Finger of 25% (5) prescription drugs and therapeutic services and supplies; Same Hand (6) dental treatment as a result of injury to sound, natural The total payment for all of the losses of an insured teeth (natural teeth in SC); because of any one accident will not be more than the face amount shown in the application. The loss of the (7) the following licensed home health care agency thumb and index finger of the same hand benefit will not services and supplies provided instead of an otherwise be paid if the loss of the hand or arm benefit applies. heT required hospital or skilled nursing home confinement: loss of the hand or foot benefit will not be paid if the loss (a) physical, occupational, respiratory and speech therapy; of the arm or leg benefit applies. (b) the services of a home health aide; and Policy Exclusions (c) medical supplies. If excess medical has been elected, we will not pay and Limitations benefits orf , nor can this plan’s deductible (if any) be We will not pay benefits orf expenses incurred for: satisfied yb , covered expenses to the extent that they are (1) the examination, prescription, purchase or fitting of collectible under certain other policies and/or health plans eyeglasses, contact lenses or hearing aids; or as stated in the policy. (2) treatment by a person employed or retained by the Coverage is provided under policy form No. GR-9041 et al. plan sponsor or its subsidiaries or affiliates and for Certain provisions of the policy are summarized in this which no charge is normally made; or brochure. All benefits are subject to the policy, which alone (3) care or treatment by a person who ordinarily lives in constitutes the agreement under which payments are made. the insured’s home or is a parent, grandparent, spouse, brother, sister or child of either the insured or the insured’s spouse (if a NJ contract, care or treatment furnished by a member of the insured’s immediate family); or (4) diathermy, light, shortwave and other heat or physiotherapy treatments in excess of the first five of all such treatments while the insured is neither hospital confined nor under the care of a home health care agency. Nor will we pay benefits orf loss or expenses resulting from: (5) intentional self-destruction or an attempt at it or intentional self-inflicted injury (if a MO contract, while sane); or (6) war or an act of war, declared or undeclared; or (7) air travel unless the insured is a passenger on a regularly scheduled flight of a properly licensed commercial airline.

4 SHC-0145AO (01/16) .) Benefit Amounts Gross Rate Per Player by Age Class

TES Medical Expense Death & Ages 9 & Under Ages 10-12 Ages 13-15 Ages 16-18 Ages 19 & Over A Specific osL s T Deductible Maximum (Face Amount) Primary Excess Primary Excess Primary Excess Primary Excess Primary Excess

BASKETBALL (004) (Five Months Standard Maximum Policy Term) The Discounts available on request for policy terms of one (1) month or less. Spe- cial Rates available for policy terms exceeding the maximum months shown. $ 0 $ 5,000 $ 10,000 $4.40 $2.25 $6.40 $2.95 $8.70 $3.80 $16.60 $6.60 $47.70 $17.75 $ 50 $ 5,000 4.20 1.80 6.10 2.25 8.25 2.80 15.70 4.60 45.00 11.70 $ 0 $ 10,000 $ 12,500 5.20 2.60 7.60 3.40 10.25 4.30 19.55 7.45 55.95 19.75 $ 50 $ 10,000 5.00 2.10 7.30 2.60 9.80 3.15 18.65 5.05 53.20 12.55 or NY see pages 9 & 10 $ 0 $ 25,000 $ 15,000 6.15 3.00 8.95 3.85 12.05 4.85 22.90 8.30 65.50 21.75 $ 50 $ 25,000 5.95 2.45 8.60 3.00 11.60 3.60 22.00 5.75 62.80 14.15 $ 100 $ 25,000 5.75 2.20 8.30 2.65 11.15 3.10 21.10 4.75 60.05 11.25 $ 0 $ 50,000 $ 17,500 NA 3.55 NA 4.65 NA 5.85 NA 10.10 NA 26.65 $ 50 $ 50,000 NA 3.10 NA 3.90 NA 4.80 NA 7.95 NA 20.25 $ 100 $ 50,000 NA 2.75 NA 3.35 NA 4.00 NA 6.30 NA 15.40 $ 0 $ 100,000 $ 20,000 NA 3.95 NA 5.10 NA 6.40 NA 10.95 NA NA $ 50 $ 100,000 NA 3.70 NA 4.70 NA 5.85 NA 9.75 NA NA $ 100 $ 100,000 NA 3.35 NA 4.15 NA 5.05 NA 8.20 NA NA $ 0 $ 250,000 $ 25,000 NA 4.60 NA 5.85 NA 7.25 NA 12.15 NA NA $ 50 $ 250,000 NA 4.35 NA 5.45 NA 6.65 NA 10.90 NA NA $ 100 $ 250,000 NA 4.00 NA 4.90 NA 5.90 NA 9.35 NA NA

OR DC, PR, VI AND ALL 50 S NETBALL (051) WRESTLING (035) (Six Months Standard Maximum Policy Term) The Discounts available on request for policy terms of one (1) es please see pages 7 & 8, f

t month or less. Special Rates available for policy terms exceeding the maximum months shown.

ta $ 0 $ 5,000 $ 10,000 $10.20 $ 5.60 $10.20 $ 5.60 $15.00 $ 7.30 $25.80 $11.20 $28.20 $12.05 $ 50 $ 5,000 9.80 4.65 9.80 4.65 14.30 5.75 24.50 8.25 26.75 8.80 0 $ 10,000 $ 12,500 12.20 6.60 12.20 6.60 17.80 8.50 30.45 12.80 33.30 13.75

TES F $ $ 50 $ 10,000 11.80 5.50 11.80 5.50 17.10 6.65 29.15 9.30 31.80 9.85 $ 0 $ 25,000 $ 15,000 14.40 7.65 14.40 7.65 20.95 9.70 35.80 14.40 39.05 15.45

or other s $ 50 $ 25,000 13.95 6.45 13.95 6.45 20.25 7.75 34.45 10.70 37.60 11.35 $ 100 $ 25,000 13.55 6.00 13.55 6.00 19.55 7.00 33.10 9.25 36.15 9.75

. (F $ 0 $ 50,000 $ 17,500 NA 9.10 NA 9.10 NA 11.65 NA 17.45 NA 18.70 V $ 50 $ 50,000 NA 8.10 NA 8.10 NA 10.00 NA 14.30 NA 15.25 $ 100 $ 50,000 NA 7.35 NA 7.35 NA 8.75 NA 11.90 NA 12.60 $ 0 $ 100,000 $ 20,000 NA 10.15 NA 10.15 NA 12.85 NA 19.05 NA NA $ 50 $ 100,000 NA 9.60 NA 9.60 NA 11.95 NA 17.35 NA NA $ 100 $ 100,000 NA 8.85 NA 8.85 NA 10.75 NA 15.05 NA NA $ 0 $ 250,000 $ 25,000 NA 11.95 NA 11.95 NA 14.90 NA 21.60 NA NA $ 50 $ 250,000 NA 11.40 NA 11.40 NA 13.95 NA 19.80 NA NA $ 100 $ 250,000 NA 10.65 NA 10.65 NA 12.75 NA 17.50 NA NA SON PREMIUM RA GYMNASTICS (036) or WEIGHT LIFTING (037) (Six Months Standard Maximum Policy Term) The Discounts available on request for policy terms of one (1) month or less. Special Rates available for policy terms exceeding the maximum months shown. , NC, OK, TX, AND W $ 0 $ 5,000 $ 10,000 $ 6.40 $ 2.95 $ 6.40 $ 2.95 $ 7.00 $ 3.15 $ 7.60 $ 3.40 $ 8.20 $ 3.60 $ 50 $ 5,000 6.10 2.25 6.10 2.25 6.65 2.40 7.25 2.55 7.80 2.65 $ 0 $ 10,000 $ 12,500 7.60 3.40 7.60 3.40 8.30 3.65 9.00 3.90 9.70 4.10 $ 50 $ 10,000 7.30 2.60 7.30 2.60 7.95 2.70 8.60 2.85 9.30 3.00 $ 0 $ 25,000 $ 15,000 8.95 3.85 8.95 3.85 9.75 4.10 10.55 4.40 11.40 4.65 $ 50 $ 25,000 8.60 3.00 8.60 3.00 9.40 3.15 10.20 3.30 10.95 3.45 $ 100 $ 25,000 8.30 2.65 8.30 2.65 9.05 2.75 9.80 2.90 10.55 3.00 $ 0 $ 50,000 $ 17,500 NA 4.65 NA 4.65 NA 4.95 NA 5.30 NA 5.60 $ 50 $ 50,000 NA 3.90 NA 3.90 NA 4.15 NA 4.40 NA 4.60 $ 100 $ 50,000 NA 3.35 NA 3.35 NA 3.50 NA 3.70 NA 3.85 TIONWIDE’S SEA $ 0 $ 100,000 $ 20,000 NA 5.10 NA 5.10 NA 5.45 NA 5.80 NA 6.15 $ 50 $ 100,000 NA 4.70 NA 4.70 NA 5.00 NA 5.30 NA 5.60

NA $ 100 $ 100,000 NA 4.15 NA 4.15 NA 4.40 NA 4.65 NA 4.65

ept AR, FL, GA, LA, MS, NY $ 0 $ 250,000 $ 25,000 NA 5.85 NA 5.85 NA 6.20 NA 6.60 NA NA c

x $ 50 $ 250,000 NA 5.45 NA 5.45 NA 5.75 NA 6.05 NA NA e $ 100 $ 250,000 NA 4.90 NA 4.90 NA 5.15 NA 5.40 NA NA DIVING (038) (Six Months Standard Maximum Policy Term) The Discounts available on request for policy terms of one (1) month or less. Special Rates available for policy terms exceeding the maximum months shown. $ 0 $ 5,000 $ 10,000 $ 6.00 $ 3.15 $ 6.00 $ 3.15 $ 6.90 $ 3.45 $ 7.80 $ 3.80 $ 8.70 $ 4.10 $ 50 $ 5,000 5.75 2.55 5.75 2.55 6.60 2.75 7.45 2.95 8.30 3.15 $ 0 $ 10,000 $ 12,500 7.20 3.70 7.20 3.70 8.25 4.05 9.30 4.40 10.35 4.75 $ 50 $ 10,000 6.90 3.00 6.90 3.00 7.95 3.20 8.95 3.40 9.90 3.65 $ 0 $ 25,000 $ 15,000 8.45 4.20 8.45 4.20 9.70 4.60 10.90 5.00 12.15 5.40 $ 50 $ 25,000 8.20 3.50 8.20 3.50 9.35 3.75 10.55 4.00 11.70 4.20 $ 100 $ 25,000 7.90 3.20 7.90 3.20 9.05 3.40 10.20 3.60 11.30 3.75 $ 0 $ 50,000 $ 17,500 NA 5.05 NA 5.05 NA 5.55 NA 6.00 NA 6.50 $ 50 $ 50,000 NA 4.45 NA 4.45 NA 4.80 NA 5.15 NA 5.50 $ 100 $ 50,000 NA 3.95 NA 3.95 NA 4.20 NA 4.50 NA 4.75 $ 0 $ 100,000 $ 20,000 NA 5.60 NA 5.60 NA 6.10 NA 6.60 NA 7.15 $ 50 $ 100,000 NA 5.25 NA 5.25 NA 5.70 NA 6.15 NA 6.60 $ 100 $ 100,000 NA 4.80 NA 4.80 NA 5.15 NA 5.50 NA 5.85 $ 0 $ 250,000 $ 25,000 NA 6.55 NA 6.55 NA 7.10 NA 7.65 NA NA $ 50 $ 250,000 NA 6.20 NA 6.20 NA 6.70 NA 7.15 NA NA $ 100 $ 250,000 NA 5.75 NA 5.75 NA 6.15 NA 6.55 NA NA

Multiple Team 4 thru 13 teams 14 thru 23 teams 24 thru 33 teams 34 thru 43 teams 44 thru 53 teams 54 or more teams Discounts = 5% discount = 6% discount = 7% discount = 8% discount = 9% discount = 10% discount

Multiple Team Discounts – All teams must have the same policy term. Teams subsequently added to the policy will not wide increase the discount. However, teams subsequently deleted from the policy will decrease the discount. Special rates of up to 80% higher apply to all public schools (private and religious schools use the rates shown above). tion 16 Na 16 Na GR-9004-4R © 20 5 SHC-0145AO (01/16) GR-9004-4R NATIONWIDE’S SEASON PREMIUM RATES FOR DC, PR, VI AND ALL 50 STATES exxccept AR, FL, GA, LA, MS, NY, NC, OK, TX, AND WV. (For other states please see pages 7 & 8, for NY see pages 9 & 10.) Special r incr Multiple T available for policy terms exceeding themaximummonthsshown. T BO yTerm) P CRICKET T (0 ARCHER SOC Medical Expense Benefit Amounts Deductible erm) he Disc olic 17), XING Multiple T $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

ease thedisc 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 T HANDBALL Disc CER 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 he Disc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (042), ounts a (043),FIELDHOCKEY(0 Y (0 a ounts ut veusyttsa em x wn. yterms exc tes av yt eques ountsav T (006)(SixMonthsS t 10), he Disc es ofupt eam Disc $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ounts a ICE HOCKEY Maximum v

250 250 250 250 250 eam 250 250 250 250 250 250 250 100 100 100 100 100 100 100 100 100 100 100 100 ailable onr BADMINT 50 50 50 50 50 50 50 50 50 50 50 50 (0 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 10 10 10 10 10 10 10 10 5, 5, 5, 5, 5, 5, 5, 5, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 18), 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 v ailable onr ount. Ho RIFLE o 80%higherapplyt ON eques ounts 4 thru13t (0 (F Specific L Dea = 5%disc ailable onr (0 (0 ac $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 31),

11), 19), 26), FL e Amount) t f eques th & 20 20 20 20 25, 25, 25, 25, 10 10 10 10 15, 15, 15, 15, MAR 12,500 12,500 12,500 12,500 17 17 17 17 or polic –Allt BOC w RO , , , , , , , , ,500 ,500 ,500 ,500 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 e OOR HOCKEY(045), t f TIAL AR WING CI os v eams ount tandar or polic er (04 y t s , t eams mus erms ofone(1)monthorles t f (0 Gr A 1), Primary eams subsequentlydelet or polic T

ges 9&Under 20), $ 17.40 $ 10.20 BO y t S $ 4.00 $ 6.50 20.65 12.20 16.60 19.80 11.80 14.40 24.25 23.40 13.95 22.60 13.55 (050),or d MaximumP os 9.80 4.80 3.85 8.90 9.10 9.30 7.65 7.85 6.30 4.60 5.65 5.45 5.30 erms ofone(1)monthorles NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA WLING 14 thru23t SQU o allpublicschools(priv = 6%disc s Ra A erms ofone(1)monthorles SH (0 t ha J ROLLER HOCKEY AI- Ex (0 12), $ 2.10 $ 8.20 $ 5.60 $ 4.25 16.40 11.70 13.15 10.95 11.95 10.75 12.95 14.25 10.15 11.40 15.25 10.65 13.80 ALAI c t 8.00 9.45 6.30 6.60 4.65 2.45 1.70 9.65 7.15 5.25 5.45 6.05 4.60 5.15 3.80 9.05 9.40 7.40 7.75 6.30 6.65 3.75 2.65 7.25 5.50 2.00 3.50 7.65 2.80 4.35 3.20 8.40 6.45 2.35 4.15 7.50 6.00 2.05 3.85 9.10 3.35 8.10 2.95 9.45 7.35 9.60 8.85 21), es v e P CHEERLEADING ount e thesamepolic eams s S (0 WIMMING olic 2 er Pla 7), A s. SpecialRa Primary

y T ges 10- $ 17.40 $ 10.20 KICKBALL $ 4.00 $ 7.80 10.55 10.80 11.10 20.65 16.60 12.20 19.80 11.80 24.25 14.40 23.40 13.95 22.60 13.55 4.80 3.85 9.10 9.40 7.55 9.80 4.60 5.65 5.45 5.30 2 (0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA erm) 4 thru33t s. SpecialRa (0 = 7%disc 32) (F 22), (0 ed fr y 12 a 13), (04 s. SpecialRa t es a T er b TENNIS t our MonthsS he Disc e andr Ex C 9), $ 2.10 $ 8.20 $ 5.60 $ 4.75 16.40 11.70 13.15 10.95 11.95 10.50 10.10 15.25 11.40 10.75 13.80 10.65 12.95 14.25 10.15 v ORKBALL c om thepolic 8.75 y t 2.45 1.70 7.85 5.50 5.80 6.60 4.95 5.65 4.10 9.45 6.30 6.60 4.65 9.60 7.90 8.40 6.65 7.15 2.65 3.75 2.00 7.25 5.50 3.50 2.80 7.65 4.35 3.20 2.35 8.40 6.45 4.15 2.05 7.50 6.00 3.85 3.35 9.10 2.95 8.10 9.45 7.35 9.60 8.85 ailable f t ount es LA es a eams (0 s y A erm. T ounts a CRO v eligious schoolsusether 23), ailable f or polic S A

tandar Primary (0 SE TRA ge Clas ges 13- $ 51.00 $ 27.00 $ 16.45 v $ 4.60 (0 34 thru43t 21.40 22.15 22.95 18.75 19.50 15.70 59.95 48.20 31.85 25.60 ailable onr 57.15 30.45 70.30 37.40 67.50 36.00 64.70 34.60 14), CRO ailable f eams subsequentlyaddedt 5.50 4.40 5.30 6.45 6.25 6.05 = 8%disc or polic NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA CK 28), d MaximumP y t (0 erms e y willdecr POL 15 or polic 2 S 4), or y t S C O eques Ex $ 20.20 $ 11.60 erms e x (0 $ 2.30 $ 7.85 OUNTR 37.10 25.00 29.80 24.25 22.30 13.70 30.85 13.40 14.75 15.80 11.35 12.70 10.60 12.45 10.35 22.75 14.00 13.25 33.30 15.35 20.40 25.30 14.90 28.50 18.00 17.50 11.00 14.50 18.05 14.75 33.40 19.25 19.70 12.25 17.90 15.50 c s c ount 3.20 2.70 1.85 9.20 7.30 8.15 7.00 9.10 6.10 8.50 2.80 4.10 2.15 9.55 3.80 3.10 4.75 3.45 2.50 4.45 2.25 9.50 4.10 3.70 eeding themaximummonthssho V 29), orS es eams olic OLLEYBALL t f s x or polic y T c Y (0 ease thedisc eeding themaximummonthssho erm)

A TREET HOCKEY(05 Primary 15), ges 16- $ 84.60 $ 43.80 $ 43.80 44 thru5 116.40 111.60 106.85 $ 5.20 y t a 55.70 58.05 60.45 49.15 51.55 41.45 99.30 79.85 51.55 41.45 94.55 49.15 60.45 58.05 55.70 eeding themaximummonthssho (Ex = 9%disc 6.20 5.00 5.95 7.30 7.05 6.80 t NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA D erms ofone(1)monthorles (0 es sho AR cludes Mix 25) (SixMonthsS TBALL 18 3 t wn abo Ex $ 32.25 $ 17.65 $ 17.65 $ 2.55 ount ount. 57.85 38.30 46.50 37.55 32.70 29.30 48.80 25.35 29.45 32.70 22.15 26.25 17.15 21.40 27.05 13.00 15.55 22.20 13.65 19.90 12.35 36.05 21.70 19.90 12.35 23.50 13.65 51.40 29.45 (044), 43.20 39.90 25.35 22.20 26.60 15.55 21.50 13.00 27.05 21.40 52.60 29.05 29.30 17.15 26.25 22.15 ed Martial c eams o thepolic 3.45 2.95 2.00 3.00 4.40 2.30 4.10 3.35 5.10 3.70 2.65 4.80 2.40 4.35 4.00 es 2) (SixMonthsS s SHC v FENCING wn.

e tandar A ). Arts andExtr Primary 54 ormor $ 147.00 $398.40 ges 19&Ov $ 75.00 500.40 523.50 546.55 443.65 375.35 466.70 172.35 138.60 163.95 201.90 103.20 193.50 185.10 -0 = 10%disc $ 5.80 88.05 70.80 83.85 99.00 94.80 wn. 6.90 5.55 6.60 8.10 7.80 7.55 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA d MaximumP 145A y willnot s. SpecialRa (0 tandar

16), O (0 eme Sports e t GOLF d Maximum Ex $144.70 $ 54.60 $ 28.80 216.15 111.60 175.85 120.60 161.80 160.30 ount $ 2.75 63.00 77.40 62.25 82.05 86.90 99.35 93.65 60.75 36.00 32.25 19.50 38.55 21.15 66.90 35.70 43.50 24.00 34.50 19.50 43.65 33.75 88.20 47.25 26.25 eams er c 3.65 3.15 2.10 4.75 3.15 2.45 4.40 3.60 3.90 2.80 2.50 4.35 1/ es NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA olic t

es 16) s y

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© 2016 Nationwide GR-9004-5J NATIONWIDE’S SEASON RATES FOR AR, FL, GA, LA, MS, NC, OK, TX, AND WV. (For DC, PR, VI and the remaining 41 statattes see pages 5 & 6, for NY see pages 9 & 10.) Special r incr Multiple T cial Rates available for policy terms exceeding themaximummonths shown. a BA DIVING t G NETBALL month orles Medical Expense Benefit Amounts erms ofone(1)monthorles Deductible v YMNA ailable f Multiple T $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SKETBALL

ease thedisc 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Disc 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 or polic (0 a S ounts s. SpecialRa t TICS es ofupt (051) eam Disc $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 38) (SixMonthsS Maximum

250 250 250 250 250 250 eam 250 250 250 250 250 250 100 100 100 100 100 100 100 100 100 100 100 100 y t 50 50 50 50 50 50 50 50 50 50 50 50 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 10 10 10 10 10 10 10 10 5, 5, 5, 5, 5, 5, 5, 5,

(004)(Fiv erms e , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , (0 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 WRES 36) or ount. Ho t es a o 80%higherapplyt x c ounts 4 thru13t s. SpecialRa eeding themaximummonthssho (F Specific L Dea = 5%disc v ailable f ac $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TLING

WEIGHT LIFTING e Amount) th & 20 20 20 20 25, 25, 25, 25, 10 10 10 10 15, 15, 15, 15, 12,500 12,500 12,500 12,500 e MonthsS 17 17 17 17 –Allt w , , , , , , , , ,500 ,500 ,500 ,500 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 or polic e tandar os v (0 t eams ount es a er s 3 , t eams mus v y t Gr A 5) (SixMonthsS ailable f Primary eams subsequentlydelet erms e

ges 9&Under $ 11.65 d MaximumP $ 6.90 $ 7.50 $ 5.05 13.90 11.15 13.40 10.40 16.35 10.05 15.85 15.35 tandar os 9.70 6.60 6.80 7.05 5.75 6.00 4.80 8.20 6.60 8.85 7.15 7.90 8.50 9.35 9.05 9.65 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 14 thru23t o allpublicschools(priv or polic = 6%disc x s Ra c eeding themaximummonthssho (0 t ha d MaximumP Ex wn. y t 3 $ 3.45 $ 3.35 $ 6.10 $ 2.45 10.30 12.85 12.15 11.30 10.95 7) (SixMonthsS c erms e t 4.35 4.60 5.00 3.95 2.35 2.60 3.25 2.25 2.85 1.95 4.30 4.70 3.60 4.00 2.95 3.35 4.05 2.75 3.85 2.50 7.20 5.00 3.75 3.20 2.85 5.85 9.45 3.40 4.35 8.25 5.55 3.30 6.85 4.80 2.85 6.30 6.10 4.20 5.25 9.90 5.70 4.35 8.70 7.10 5.15 5.70 3.65 7.80 5.25 6.70 6.15 6.50 4.60 6.00 5.35 es v e P ount e thesamepolic eams olic s tandar x c er Pla y T eeding themaximummonthssho A Primary

ges 10- $ 11.65 $ 6.90 $ 7.50 $ 7.50 10.05 10.40 13.90 11.15 13.40 16.35 10.40 15.85 10.05 15.35 erm) 9.65 8.50 8.85 7.15 9.70 8.20 6.60 8.85 7.15 9.35 7.90 8.50 9.05 9.65 2 d MaximumP NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA olic 4 thru33t = 7%disc ed fr y T y T 12 a he Disc er b tandar t e andr Ex erm) $ 6.10 $ 3.45 $ 3.35 $ 3.35 wn. 10.30 12.85 12.15 11.30 10.95 c om thepolic 5.70 y t 6.50 5.25 2.85 3.30 4.35 2.85 3.85 2.50 4.60 7.20 5.00 5.35 6.00 4.60 5.25 3.65 4.35 4.05 2.75 3.85 2.50 5.85 3.75 3.20 2.85 9.45 3.40 8.25 4.35 5.55 6.85 3.30 4.80 6.30 2.85 6.10 4.20 9.90 5.25 5.70 8.70 4.35 7.10 5.15 7.80 5.70 3.65 6.70 5.25 6.15 6.50 4.60 6.00 5.35 ount es ounts a eams s y A erm. T T d MaximumP eligious schoolsusether he Disc olic A

v Primary ailable onr ge Clas ges 13- $ 17.40 $ 10.25 y T $ 8.00 $ 8.20 34 thru43t 13.10 13.60 14.15 11.55 12.05 11.15 20.65 16.60 19.80 10.80 10.40 24.25 11.40 23.40 10.95 22.60 10.55 eams subsequentlyaddedt ounts a 9.70 9.50 7.65 9.70 7.80 9.10 9.30 = 8%disc NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA wn. erm) y willdecr 15 v eques ailable onr Ex T olic he Disc $ 8.20 $ 3.85 $ 3.60 $ 4.35 13.15 16.40 15.25 13.80 11.70 10.75 12.95 10.95 14.25 s c ount 7.30 6.55 7.50 8.20 5.65 6.60 4.45 5.40 6.70 3.45 4.00 5.50 3.50 4.90 3.15 5.10 9.45 6.30 4.45 3.00 4.10 2.65 4.05 7.25 3.45 3.00 3.60 4.65 6.10 8.40 3.45 5.20 7.50 3.00 6.70 4.55 5.60 6.25 4.60 7.75 5.60 9.45 6.15 3.85 7.25 5.60 6.60 6.95 4.85 6.40 5.65 t f es eams y T or polic s ounts a eques erm) ease thedisc

A Primary y t ges 16- $ 30.40 $ 19.75 44 thru5 t f $ 9.10 $ 8.95 a 35.80 28.80 25.00 26.10 27.20 22.10 23.20 18.65 12.65 10.75 10.55 12.20 34.20 10.30 10.10 42.05 11.75 12.40 40.45 11.90 38.85 11.45 erms ofone(1)monthorles v = 9%disc 8.65 8.50 ailable onr or polic t T NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA es sho he Disc 18 y t ounts a 3 t wn abo Ex erms ofone(1)monthorles $ 12.85 eques $ 4.25 $ 3.85 $ 7.75 ount ount. 19.60 12.70 24.40 22.25 19.50 21.65 10.70 12.60 14.05 11.30 11.75 14.60 10.40 16.85 16.40 11.95 10.20 19.85 16.10 13.25 c eams o thepolic 9.45 7.25 9.20 5.40 6.60 9.65 5.80 8.70 5.30 9.30 5.55 4.90 3.25 4.40 2.85 4.30 3.75 3.20 3.85 4.95 6.70 3.65 5.65 3.15 7.35 4.85 6.00 6.75 4.90 8.45 6.00 6.55 4.10 7.85 5.95 7.10 7.40 5.15 6.80 6.00 es v s t f ailable onr SHC or polic v

e A ). Primary 54 ormor ges 19&Ov $ 33.25 $ 57.05 $10.15 -0 = 10%disc $ 9.65 14.10 71.80 75.05 78.30 63.60 53.75 66.85 12.00 11.40 39.20 31.50 13.60 11.50 10.90 37.40 13.10 13.35 46.00 12.85 44.20 12.35 42.45 y t 9.65 9.15 s. SpecialRa NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 145A eques y willnot erms ofone(1)

t f O (0 e t or polic Ex $ 21.10 $13.85 ount s. Spe $ 4.60 $ 4.10 31.65 13.20 16.70 25.80 14.80 13.85 15.75 18.10 23.95 23.45 11.10 17.65 12.70 10.80 21.40 17.25 14.10 eams t er c 6.00 5.30 3.50 4.70 3.00 9.95 4.60 4.00 3.35 es 4.05 5.25 7.25 3.85 6.05 3.30 7.95 5.15 6.40 7.30 5.20 6.45 6.95 4.30 6.30 5.45 1/ es NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 16) s y -

© 2016 Nationwide 8 GR-9004-5J NATIONWIDE’S SEASON RATES FOR AR, FL, GA, LA, MS, NC, OK, TX, AND WV. (For DC, PR, VI and the remaining 41 states see pages 5 & 6, for NY see pages 9 & 10.) Special r incr Multiple T available for policy terms exceeding themaximummonthsshown. P CRICKET T (0 ARCHER SOC T BO Medical Expense Benefit Amounts Deductible erm) he Disc olic 17), XING Multiple T $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ y T

ease thedisc 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 T HANDBALL Disc CER 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 erm) he Disc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (042), ounts a (043),FIELDHOCKEY(0 Y (0 a ounts T (006)(SixMonthsS t 10), he Disc es ofupt eam Disc $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ounts a ICE HOCKEY Maximum v

250 250 250 250 250 eam 250 250 250 250 250 250 250 100 100 100 100 100 100 100 100 100 100 100 100 ailable onr BADMINT 50 50 50 50 50 50 50 50 50 50 50 50 (0 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 10 10 10 10 10 10 10 10 5, 5, 5, 5, 5, 5, 5, 5, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 18), 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 ounts a 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 v ailable onr ount. Ho RIFLE o 80%higherapplyt ON eques ounts v 4 thru13t (0 (F Specific L Dea = 5%disc ailable onr (0 (0 ac $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 31),

11), 19), 26), FL e Amount) t f eques th & 20 20 20 20 25, 25, 25, 25, 10 10 10 10 15, 15, 15, 15, MAR 12,500 12,500 12,500 12,500 17 17 17 17 or polic –Allt BOC w RO , , , , , , , , ,500 ,500 ,500 ,500 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 e OOR HOCKEY(045), t f eques TIAL AR WING CI os v eams ount tandar or polic er (04 y t s , t eams mus erms ofone(1)monthorles t f (0 Gr A 1), Primary eams subsequentlydelet or polic T

ges 9&Under 20), $ 20.30 $ 11.65 BO y t S $ 4.60 $ 7.20 13.90 10.25 24.00 19.30 11.15 10.00 13.40 23.00 16.35 28.20 15.85 27.20 26.20 15.35 (050),or d MaximumP os 5.50 4.40 9.75 8.40 8.65 6.95 5.30 6.45 6.25 6.05 erms ofone(1)monthorles NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA WLING 14 thru23t SQU o allpublicschools(priv = 6%disc y t s Ra A erms ofone(1)monthorles SH (0 t ha J ROLLER HOCKEY AI- Ex (0 12), $ 2.30 $ 9.20 $ 6.10 $ 4.50 12.85 10.30 10.10 10.60 18.20 12.85 14.60 10.30 12.10 12.00 14.50 15.90 10.95 12.15 16.80 11.30 15.10 ALAI c t 8.40 7.20 5.00 2.70 1.85 7.50 5.40 5.65 6.35 4.80 5.45 4.00 9.35 9.75 7.70 8.10 6.50 6.95 7.00 4.10 2.80 5.85 2.15 7.95 3.80 8.25 3.10 4.75 3.45 6.85 2.50 9.20 4.45 8.10 6.30 2.25 4.10 9.90 3.70 8.70 3.20 7.80 9.45 21), es v e P CHEERLEADING ount e thesamepolic eams s S (0 WIMMING olic 2 er Pla 7), A s. SpecialRa Primary

y T ges 10- $ 20.30 $ 11.65 KICKBALL $ 4.60 $ 8.80 11.75 12.10 12.40 10.20 10.50 13.90 11.15 24.00 19.30 13.40 23.00 16.35 28.20 15.85 27.20 15.35 26.20 5.50 4.40 8.45 5.30 6.45 6.25 6.05 2 (0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA erm) 4 thru33t s. SpecialRa (0 = 7%disc 32) (F 22), (0 ed fr y 12 a 13), (04 s. SpecialRa t es a T er b TENNIS t our MonthsS he Disc e andr Ex C 9), $ 2.30 $ 9.20 $ 6.10 $ 5.10 11.10 18.20 12.85 14.60 10.30 12.10 12.85 10.30 10.05 10.60 10.60 12.15 16.80 12.00 11.30 15.10 14.50 10.95 15.90 v ORKBALL c om thepolic 9.30 y t 2.70 1.85 8.35 5.70 6.10 7.00 5.15 6.05 4.35 7.20 5.00 8.30 8.90 6.95 7.55 7.00 2.80 4.10 2.15 7.95 5.85 3.80 3.10 8.25 4.75 3.45 2.50 6.85 9.20 4.45 2.25 8.10 6.30 4.10 3.70 9.90 3.20 8.70 7.80 9.45 ailable f t ount es LA es a eams (0 s y A erm. T ounts a CRO v eligious schoolsusether 23), ailable f t es a or polic S A

tandar Primary (0 SE TRA ge Clas ges 13- $ 60.60 $ 31.80 $ 19.15 v v $ 5.35 (0 34 thru43t 24.75 25.70 26.65 21.70 22.65 18.20 37.50 30.15 71.20 57.25 ailable onr 35.80 67.85 44.00 83.50 42.30 80.10 40.65 76.75 14), CRO ailable f eams subsequentlyaddedt 6.35 5.10 6.10 7.45 7.20 6.95 = 8%disc or polic NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA CK 28), d MaximumP y t (0 erms e y willdecr POL 15 or polic 2 S 4), or y t S C O eques Ex $ 23.65 $ 13.35 erms e x (0 $ 2.55 $ 8.80 OUNTR 17.45 25.30 20.30 43.05 28.80 34.60 22.05 28.05 15.25 36.00 14.60 16.20 12.40 14.00 10.00 11.65 13.90 11.50 10.15 15.15 26.55 16.20 23.00 10.75 38.50 17.70 17.00 32.70 29.50 20.10 12.30 20.10 10.50 16.50 20.65 16.65 22.45 13.65 38.90 17.40 c s c ount 3.50 3.00 2.00 7.90 8.90 7.65 6.70 9.60 3.05 4.50 2.30 4.15 3.40 5.20 3.75 2.70 4.85 2.40 4.40 4.10 eeding themaximummonthssho V 29), orS es eams y t olic OLLEYBALL t f s erms e x or polic y T c Y (0 ease thedisc eeding themaximummonthssho erm)

A TREET HOCKEY(05 Primary $ 100.95 x 15), ges 16- $ 52.00 $ 52.00 44 thru5 118.40 112.70 138.75 133.05 127.35 c $ 6.05 y t a 65.95 68.80 71.65 58.25 61.10 49.15 95.25 61.10 49.15 58.25 71.65 68.80 65.95 eeding themaximummonthssho (Ex = 9%disc 7.20 5.75 6.90 8.45 8.15 7.85 t NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA D erms ofone(1)monthorles (0 es sho AR cludes Mix 25) (SixMonthsS TBALL 18 3 t wn abo Ex $ 38.10 $ 20.55 $ 20.55 $ 2.85 ount ount. 37.70 37.70 30.30 67.90 44.80 54.60 33.85 44.05 33.95 57.50 28.95 33.85 25.40 30.30 19.55 24.65 31.40 14.70 17.80 25.75 15.60 23.15 14.25 23.15 14.25 42.55 25.45 15.60 27.45 33.85 60.15 (044), 28.95 25.75 50.35 46.95 17.80 31.05 14.70 24.90 31.40 24.65 33.95 19.55 61.90 25.40 ed Martial c eams o thepolic 3.75 3.25 2.20 3.25 4.90 2.50 4.50 3.70 5.65 4.00 2.90 5.25 2.55 4.75 4.45 es 2) (SixMonthsS s SHC v FENCING wn.

e tandar A ). Arts andExtr Primary 54 ormor $ 175.80 $ 477.50 ges 19&Ov $ 89.40 599.60 627.30 654.95 531.65 449.85 559.30 104.95 206.10 165.75 196.00 122.95 241.40 117.90 231.30 112.90 221.25 -0 = 10%disc $ 6.80 84.40 99.90 wn. 8.00 6.45 7.70 9.40 9.10 8.75 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA d MaximumP 145A y willnot s. SpecialRa (0 tandar

16), wn. O (0 eme Sports e t GOLF d Maximum $ 173.05 Ex $ 64.95 $ 34.00 258.35 103.35 133.05 210.15 118.45 111.75 143.65 193.10 191.60 104.65 ount $ 3.10 74.40 91.70 55.65 73.65 97.45 72.15 42.60 37.95 22.80 24.65 45.55 41.95 79.40 51.30 27.90 22.50 40.50 51.35 39.45 30.45 eams er c 4.05 3.55 2.35 5.30 3.45 2.65 4.90 4.00 4.30 3.10 2.70 4.85 1/ es NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA olic t es 16) s y

)

© 2016 Nationnw GR-9004-6C NATIONWIDE’S NEW YORK SEASON PREMIUM RATES. (For DC, PR, VI and the remaining 49 states see pages 5-8.) Special r incr Multiple T cial Ra a BA DIVING t G NETBALL month orles Medical Expense Benefit Amounts erms ofone(1)monthorles Deductible v YMNA ailable f Multiple T $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SKETBALL

ease thedisc 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Disc t 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 es a 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 or polic (0 a v S ounts ailable f s. SpecialRa t TICS es ofupt (051) eam Disc $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 38) (SixMonthsS Maximum

(004)(Fiv erms e or polic , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , (0 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 WRES 36) or ount. Ho t es a o 80%higherapplyt x y t c ounts 4 thru13t s. SpecialRa eeding themaximummonthssho (F Specific L Dea = 5%disc v erms e ailable f ac $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TLING

WEIGHT LIFTING e Amount) th & 20 20 20 20 25, 25, 25, 25, 10 10 10 10 15, 15, 15, 15, 12,500 12,500 12,500 12,500 e MonthsS 17 17 17 17 –Allt x w , , , , , , , , ,500 ,500 ,500 ,500 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 c or polic eeding themaximummonthssho e tandar os v (0 t eams ount es a er s 3 , t eams mus v y t Gr A 5) (SixMonthsS ailable f Primary eams subsequentlydelet erms e

ges 9&Under $ 10.20 d MaximumP $ 6.00 $ 6.40 $ 4.40 12.20 11.80 14.40 13.95 13.55 tandar os 8.45 5.75 5.95 6.15 5.00 5.20 4.20 7.20 5.75 7.60 6.10 9.80 6.90 7.30 8.20 7.90 8.95 8.60 8.30 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 14 thru23t o allpublicschools(priv or polic = 6%disc x s Ra c eeding themaximummonthssho (0 t ha d MaximumP Ex wn. y t 3 $ 3.15 $ 2.95 $ 5.60 $ 2.25 11.95 11.40 10.65 10.15 7) (SixMonthsS c erms e t 3.95 4.20 4.60 3.55 2.20 2.45 3.00 2.10 2.60 1.80 4.00 4.35 3.35 3.70 2.75 3.10 3.70 2.55 3.40 2.25 9.60 6.60 4.65 3.50 3.00 2.60 5.50 8.85 3.20 3.85 7.65 5.05 3.00 6.45 4.45 2.65 6.00 5.60 3.95 4.65 9.10 5.25 3.90 8.10 6.55 4.80 5.10 3.35 7.35 4.70 6.20 5.75 5.85 4.15 5.45 4.90 es v e P ount e thesamepolic eams olic s tandar x wn. c er Pla y T eeding themaximummonthssho A Primary

ges 10- $ 10.20 $ 6.00 $ 6.40 $ 6.30 12.20 11.80 14.40 13.95 13.55 erm) 8.15 8.45 8.75 7.15 7.45 6.00 8.45 9.80 7.20 5.75 7.60 6.10 8.20 6.90 7.30 7.90 8.95 8.60 8.30 2 d MaximumP NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA olic 4 thru33t = 7%disc ed fr y T y T 12 a he Disc er b tandar t e andr Ex erm) $ 5.60 $ 3.15 $ 2.95 $ 2.90 wn. 11.95 11.40 10.65 10.15 c om thepolic 5.05 y t 5.60 4.60 2.60 2.95 3.80 2.55 3.35 2.25 4.20 6.60 4.65 4.85 5.35 4.10 4.65 3.30 3.85 3.70 2.55 3.40 2.25 9.60 5.50 3.50 3.00 2.60 8.85 3.20 7.65 3.85 5.05 3.00 6.45 4.45 6.00 2.65 5.60 3.95 9.10 4.65 5.25 8.10 3.90 6.55 4.80 7.35 5.10 3.35 6.20 4.70 5.75 5.85 4.15 5.45 4.90 ount es ounts a eams s y A erm. T T d MaximumP eligious schoolsusether he Disc olic A

v Primary ailable onr ge Clas ges 13- $ 15.00 y T $ 6.90 $ 7.00 $ 8.70 34 thru43t 11.15 11.60 12.05 10.25 17.80 14.30 17.10 20.95 20.25 19.55 eams subsequentlyaddedt ounts a 9.80 8.25 9.70 8.25 6.60 8.30 6.65 9.35 7.95 7.95 9.05 9.75 9.40 9.05 = 8%disc NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA wn. erm) y willdecr 15 v eques ailable onr Ex T olic he Disc $ 7.30 $ 3.45 $ 3.15 $ 3.80 14.90 13.95 12.75 11.95 10.75 11.65 10.00 12.85 s c ount 6.40 5.90 6.65 7.25 5.05 5.85 4.00 4.80 5.85 3.10 3.60 4.85 3.15 4.30 2.80 4.60 8.50 5.75 4.05 2.75 3.65 2.40 3.75 6.65 3.20 2.70 3.40 9.70 4.10 5.55 7.75 3.15 4.80 7.00 2.75 6.10 4.20 4.95 5.70 4.15 7.10 5.15 8.75 5.45 3.50 6.70 5.00 6.15 6.20 4.40 5.75 5.15 t f es eams y T or polic s ounts a eques erm) ease thedisc

A Primary y t ges 16- $ 25.80 $ 16.60 44 thru5 t f $ 7.80 $ 7.60 a 30.45 24.50 21.10 22.00 22.90 18.65 19.55 15.70 10.90 10.55 29.15 35.80 10.20 10.55 34.45 10.20 33.10 erms ofone(1)monthorles v = 9%disc 9.30 7.45 9.00 7.25 8.95 8.60 9.80 ailable onr or polic t T NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA es sho he Disc 18 y t ounts a 3 t wn abo Ex erms ofone(1)monthorles $ 11.20 eques $ 3.80 $ 3.40 $ 6.60 ount ount. 10.95 21.60 19.80 17.50 19.05 10.90 12.15 10.10 12.80 17.35 15.05 14.40 10.70 17.45 14.30 11.90 c eams o thepolic 9.35 8.20 9.75 6.30 7.95 4.75 5.75 8.30 5.05 7.45 4.60 8.25 5.00 4.40 2.95 3.90 2.55 9.30 4.00 3.40 2.85 3.60 4.40 6.00 3.30 5.15 9.25 2.90 6.60 4.50 5.30 6.15 4.40 7.65 5.50 5.80 3.70 7.15 5.30 6.55 6.60 4.65 6.05 5.40 es v s t f ailable onr SHC or polic v

e A ). Primary 54 ormor ges 19&Ov $ 28.20 $ 47.70

-0 = 10%disc $ 8.70 $ 8.20 12.15 60.05 62.80 65.50 53.20 45.00 55.95 10.35 33.30 26.75 11.70 31.80 11.30 11.40 39.05 10.95 37.60 10.55 36.15 y t 8.30 9.70 7.80 9.90 9.30 s. SpecialRa NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 145A eques y willnot erms ofone(1)

t f O (0 e t or polic Ex ount s. Spe eams t er c es 1/ es NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

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© 2016 Nationwide 10 GR-9004-6C NATIONWIDE’S NEW YORK SEASON PREMIUM RATES. (For DC, PR, VI and the remaining 49 states see pages 5-8.) Special r incr Multiple T a P CRICKET T (0 ARCHER SOC T BO Medical Expense Benefit Amounts Deductible erm) v he Disc olic ailable f 17), XING Multiple T $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ y T

ease thedisc 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 T HANDBALL Disc CER 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 erm) he Disc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (042), ounts a (043),FIELDHOCKEY(0 Y or polic (0 a ounts T (006)(SixMonthsS t 10), he Disc es ofupt eam Disc $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ounts a ICE HOCKEY Maximum v

250 250 250 250 250 eam 250 250 250 250 250 250 250 100 100 100 100 100 100 100 100 100 100 100 100 ailable onr BADMINT y t 50 50 50 50 50 50 50 50 50 50 50 50 (0 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 25, 10 10 10 10 10 10 10 10 5, 5, 5, 5, 5, 5, 5, 5, erms e , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 18), 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 ounts a 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 v ailable onr ount. Ho RIFLE o 80%higherapplyt x ON c eques ounts v 4 thru13t (0 eeding themaximummonthssho (F Specific L Dea = 5%disc ailable onr (0 (0 ac $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 31),

11), 19), 26), FL e Amount) t f eques th & 20 20 20 20 25, 25, 25, 25, 10 10 10 10 15, 15, 15, 15, MAR 12,500 12,500 12,500 12,500 17 17 17 17 or polic –Allt BOC w RO , , , , , , , , ,500 ,500 ,500 ,500 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 e OOR HOCKEY(045), t f eques TIAL AR WING CI os v eams ount tandar or polic er (04 y t s , t eams mus erms ofone(1)monthorles t f (0 Gr A 1), Primary eams subsequentlydelet or polic T

ges 9&Under 20), $ 17.40 $ 10.20 BO y t S $ 4.00 $ 6.50 12.20 20.65 16.60 11.80 19.80 14.40 24.25 13.95 23.40 22.60 13.55 (050),or d MaximumP os 9.80 4.80 3.85 8.90 9.10 9.30 7.65 7.85 6.30 4.60 5.65 5.45 5.30 erms ofone(1)monthorles NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA WLING 14 thru23t SQU o allpublicschools(priv = 6%disc y t s Ra A erms ofone(1)monthorles SH (0 t ha J ROLLER HOCKEY AI- Ex wn. (0 12), $ 2.10 $ 8.20 $ 5.60 $ 4.25 11.95 16.40 11.70 13.15 10.95 10.75 12.95 14.25 10.15 11.40 15.25 10.65 13.80 ALAI c t 8.00 6.60 4.65 2.45 1.70 9.65 7.15 5.25 5.45 6.05 4.60 5.15 3.80 9.05 9.40 7.40 7.75 6.30 6.65 9.45 6.30 3.75 2.65 5.50 2.00 7.25 3.50 7.65 2.80 4.35 3.20 6.45 2.35 8.40 4.15 7.50 6.00 2.05 3.85 9.10 3.35 8.10 2.95 9.45 7.35 9.60 8.85 21), es v e P CHEERLEADING ount e thesamepolic eams s S (0 WIMMING olic 2 er Pla 7), A s. SpecialRa Primary

y T ges 10- $ 17.40 $ 10.20 KICKBALL $ 4.00 $ 7.80 10.55 10.80 11.10 12.20 20.65 16.60 11.80 19.80 14.40 24.25 13.95 23.40 13.55 22.60 4.80 3.85 9.10 9.40 7.55 9.80 4.60 5.65 5.45 5.30 2 (0 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA erm) 4 thru33t s. SpecialRa (0 = 7%disc 32) (F 22), (0 ed fr y 12 a 13), (04 s. SpecialRa t es a T er b TENNIS t our MonthsS he Disc e andr Ex C 9), $ 2.10 $ 8.20 $ 5.60 $ 4.75 16.40 11.70 13.15 10.95 11.95 10.50 10.10 11.40 15.25 10.75 10.65 13.80 12.95 10.15 14.25 v ORKBALL c om thepolic 8.75 y t 2.45 1.70 7.85 5.50 5.80 6.60 4.95 5.65 4.10 6.60 4.65 9.60 7.90 8.40 6.65 7.15 9.45 6.30 2.65 3.75 2.00 7.25 5.50 3.50 2.80 7.65 4.35 3.20 2.35 6.45 8.40 4.15 2.05 7.50 6.00 3.85 3.35 9.10 2.95 8.10 7.35 9.45 9.60 8.85 ailable f t ount es LA es a eams (0 s y A erm. T ounts a CRO v eligious schoolsusether 23), ailable f t es a or polic S A

tandar Primary (0 SE TRA ge Clas ges 13- $ 51.00 $ 27.00 $ 16.45 v v $ 4.60 (0 34 thru43t 21.40 22.15 22.95 18.75 19.50 15.70 31.85 25.60 59.95 48.20 ailable onr 30.45 57.15 37.40 70.30 36.00 67.50 34.60 64.70 14), CRO ailable f eams subsequentlyaddedt 5.50 4.40 5.30 6.45 6.25 6.05 = 8%disc or polic NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA CK 28), d MaximumP y t (0 erms e y willdecr POL 15 or polic 2 S 4), or y t S C O eques Ex $ 20.20 $ 11.60 erms e x (0 $ 2.30 $ 7.85 OUNTR 22.30 37.10 25.00 29.80 24.25 13.70 30.85 13.40 14.75 15.80 11.35 12.70 10.60 12.45 10.35 13.25 22.75 14.00 20.40 33.30 15.35 14.90 28.50 25.30 18.00 11.00 17.50 14.50 18.05 14.75 19.70 12.25 33.40 19.25 17.90 15.50 c s c ount 3.20 2.70 1.85 9.20 7.30 8.15 7.00 9.10 6.10 8.50 2.80 4.10 2.15 9.55 3.80 3.10 4.75 3.45 2.50 4.45 2.25 9.50 4.10 3.70 eeding themaximummonthssho V 29), orS es eams y t olic OLLEYBALL t f s erms e x or polic y T c Y (0 ease thedisc eeding themaximummonthssho erm)

A TREET HOCKEY(05 Primary x 15), ges 16- $ 84.60 $ 43.80 $ 43.80 44 thru5 116.40 111.60 106.85 c $ 5.20 y t a 55.70 58.05 60.45 49.15 51.55 41.45 99.30 79.85 51.55 41.45 49.15 94.55 60.45 58.05 55.70 eeding themaximummonthssho (Ex = 9%disc 6.20 5.00 5.95 7.30 7.05 6.80 t NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA D erms ofone(1)monthorles (0 es sho AR cludes Mix 25) (SixMonthsS TBALL 18 3 t wn abo Ex $ 32.25 $ 17.65 $ 17.65 $ 2.55 ount ount. 32.70 57.85 38.30 46.50 37.55 29.30 48.80 25.35 29.45 32.70 22.15 26.25 17.15 21.40 27.05 13.00 15.55 22.20 13.65 19.90 12.35 19.90 12.35 36.05 21.70 13.65 23.50 29.45 51.40 (044), 25.35 22.20 43.20 39.90 15.55 26.60 13.00 21.50 27.05 21.40 29.30 17.15 52.60 29.05 26.25 22.15 ed Martial c eams o thepolic 3.45 2.95 2.00 3.00 4.40 2.30 4.10 3.35 5.10 3.70 2.65 4.80 2.40 4.35 4.00 es 2) (SixMonthsS s SHC v FENCING wn.

e tandar A ). Arts andExtr Primary 54 ormor $ 147.00 $ 398.40 ges 19&Ov $ 75.00

500.40 523.50 546.55 443.65 375.35 466.70 172.35 138.60 163.95 103.20 201.90 193.50 185.10 -0 = 10%disc $ 5.80 88.05 70.80 83.85 99.00 94.80 wn. 6.90 5.55 6.60 8.10 7.80 7.55 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA d MaximumP 145A y willnot s. SpecialRa (0 tandar

16), wn. O (0 eme Sports e t GOLF d Maximum Ex ount eams er c 1/ es NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA olic t

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© 2016 Nationwide How do you apply Fraud Warnings and pay for coverage? CA) For your protection California law requires the following to appear on this form. Complete ALL fields on the application. Be Any person who knowingly presents a false or fraudulent claim for the payment of a sure to sign and date where indicated. We loss is guilty of a crime and may be subject to fines and confinement in state prison. need to receive the completed application and premium payment BEFORE the (FL) Any person who knowingly and with intent to injure, defraud, or deceive any desired policy effective date. insurance company files a statement of laimc or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

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