January 6, 2016

BCLA Insurance Information

$5 Million Liability Insurance Coverage The BC Lacrosse Association’s insurance carrier is Special Risk Insurance Managers for our Liability Insurance and Sports Injury Medical and Dental Insurance. The posted new Certificate of $5 Million Liability Insurance will begin March 1, 2016 and you can forward this to your facilities. All BCLA associations, teams, and clubs are covered under this insurance, whether or not your area appears on the attached list. However, if your district is not mentioned on the list and your facility requests this specifically, please e-mail Rochelle: [email protected] so that it can be added. Please add this to your Risk Management binder. If your club or association does not have a Risk Management binder, please E-Mail: [email protected] at the BCLA Office and one will be sent to you. Directors/Officers Liability Coverage (Wrongful Acts/Errors & Omissions) The Directors/Officers Liability Coverage is $2 Million coverage. This insurance covers all directors/officers, including all BCLA member association/club/team directors and officers. Following is Special Risk Insurance Managers examples of the list of covered wrongful acts/errors & omissions: Discrimination (age, race or sex) Suspension of coaches Acts beyond granted authority Financial decline Insufficient administration or supervision resulting in losses Waste of association assets Continual absence from board meetings (negligent attention) False or misleading reports Failure to deliver services Causing the Association to incur unnecessary tax liabilities PLEASE NOTE: Under certain circumstances, coverage may be restricted. If the individual is involved in a criminal act or an “intent to injure”, insurance will not apply. Sports Injury Insurance and Claim Form Following this letter is a schedule outlining the Sports Injury Insurance and a copy of the Notification of Claim Form (aka Accident Claim Form) which should be used should any of your players or game personnel (i.e., coaches, referees, bench officials, etc.) receive injuries while participating in lacrosse activities. This Accident Claim Form is also available on the BCLA Website www.bclacrosse.com under FORMS, ADMINISTRATION.

PLEASE NOTE: The insurance claim must be made within 30 days of the injury. This means that the forms must be at the BCLA Office within that 30-day period. It is also important to note that your players must have the basic B.C. Medical Coverage. The insurance offered is for sport injury medical and dental coverage only. We recognize that within 30 days, you may not have all of the documentation, and that is understandable; however, please ensure that the claim form and doctor or dental forms are submitted within the deadline. Any subsequent receipts can be submitted within one year of the claim.

Medical/Dental Coverage It is the responsibility of individual clubs/teams personnel to ensure that your players have the appropriate BASIC medical coverage as outlined in the BCLA General Operating Policy, REGULATION 7: PLAYER REGISTRATION, 7.06: All members must have medical insurance (equivalent to BC Medical Insurance coverage). Members without a BC Care Card must provide proof of basic health insurance.

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Please note that if the individual is covered under another extended medical/dental plan, that plan will take priority, and this plan is considered as excess coverage. It is the responsibility of the athlete (or parent/guardian of athlete) to complete and submit the claim and subsequent receipts within the appropriate deadlines. Coverage of physiotherapy and massage only applies to the injury sustained and coverage is up to $300.00 per accident. Braces will only be covered up to $300.00 per accident, only if the injury causes the individual to wear the brace during regular, daily activities. The maximum payable for our blanket dental coverage is $5,000. Future dental costs have been increased to $2,000, so our dental coverage is up to a maximum of $7,000 which includes future dental coverages. Loss of Work Insurance Coverage The B.C. Lacrosse Association DOES NOT CARRY Loss of Work (income or wages) Insurance Coverage. Please let your players know this as it is incumbent on your Club/Association to relay this information to your athletes, coaches, referees and executive members. Fundraising/Special Event/Registration Days Liability Insurance Coverage If you are holding a special event on behalf of your association (i.e., raffle, display, etc.) in a location other than your arena (i.e., mall), you will require a special certificate naming the location, the location’s address, fax number and the dates of your special event. Please forward this information to Rochelle at the BCLA Office, and a copy of the insurance certificate required will be e-mailed or faxed back to you. If you are having alcohol at an event, you will require additional coverage at your club’s/association’s expense. An application form for Special Event (serving alcohol) is available on the BCLA Website under FORMS, ADMINISTRATION. As well, if you are holding a national championship and/or tournament, you may require additional coverage at your expense. Please check with [email protected].

Medical While Traveling Out Of Country The traveling team manager or coach must fill out the Out-of-Province/Country Travel Permission Form located on the BCLA Website www.bclacrosse.com under FORMS, ADMINISTRATION. Please remember to include the team personnel who will also be traveling. For out of country travel only – The BC Lacrosse Association carries Out-of-Country Medical Insurance within our insurance package for teams whose individuals are all currently registered members (athletes, coaches and team personnel, managers, chaperones and referees) traveling out of country, as long as a travel permit has been submitted with a list of all people traveling, and as long as the travel permit is approved by the BCLA and respective Directorate/League. The same policies apply – athletes must be currently registered and coaches must be currently registered and properly certified. For the 2016-2017 year (ending February 28, 2017), this cost will be absorbed by the BC Lacrosse Association.

Sessions, Camps, Clinics, etc. All of the following rules must be followed for a Camp, Session and/or Clinic to be a BCLA-sanctioned event and the event and all its players to be insured under the BCLA Liability and/or Accident Medical/Dental Insurance Program. It is the responsibility of the Host Association to ensure that: 1. The Minor Box Camp Application form must be filled out and submitted to the BCLA Office. 2. All players must be currently registered with the BC Lacrosse Association. 3. All Camps have the approval of their Local Lacrosse Association Executive/Board. 4. All Camps, Sessions and Clinics must have the approval of the BC Lacrosse Association. 5. All instructors, including current Senior/Junior/Intermediate athletes, have the appropriate NCCP Coach Certification. 6. All adult instructors have completed a criminal record check within the last three years. 7. Any Minor Box athletes participating with assisting camp instructors must wear all of their appropriate protective equipment, including a mouthguard. 8. When on the floor or field, instructors should wear the appropriate protective equipment.

If you have any questions or concerns regarding insurance, please don’t hesitate to contact Rochelle at the BCLA Office (604) 421-9755 Ext. 4 or E-mail: [email protected].

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#103, 8411-200th Street, Langley, BC V2Y 0E7 Telephone: (604) 888-0050 Fax: (604) 888-1008

CERTIFICATE OF INSURANCE

Name of Insured: Lacrosse Association

Address: Suite 101, 7382 Winston Street, Burnaby, BC V5A 2G9

THIS CERTIFICATE IS ISSUED AT THE REQUEST OF

Name: British Columbia Lacrosse Association

Name of Insurer: Lloyd’s Underwriters through Special Risk Insurance Managers Ltd.

Policy No: SR007780

Policy Period: 12:01am March 01, 2016 to 12:01am March 01, 2017

LIMITS OF LIABILITY

$5,000,000.00 INCLUSIVE LIMIT BODILY INJURY AND $5,000,000.00 AGGREGATE PROPERTY DAMAGE COMBINED $250,000.00 TENANTS LEGAL LIABILITY (Broadform) Cross Liability Clause

Reimbursement Clause: $1,000.00

OPERATIONS AND LOCATIONS TO WHICH THIS CERTIFICATE APPLIES:

Activities of the named insured with respect to

ADDITIONAL INSUREDS: It is hereby understood and agreed that the following entity shown below is added as Additional Insured, but only with respect to liability arising out of Named Insured’s premises or operations, and only with respect to losses which would have been recoverable in the absence of this agreement. The policy limits are not increased by the addition of such Additional Insured(s) and remain as stated in this Certificate:

PLEASE SEE ATTACHED LIST OF ADDITIONAL INSUREDS

The insurance afforded is subject to terms, conditions, and exclusions of the applicable policy. The Insurer will mail to the holder of this Certificate 30 (thirty) days written notice of termination except for non-payment of premium to which 15 (fifteen) days notice applies.

SPECIAL RISK INSURANCE MANAGERS LTD.

March 1, 2016 Date Authorized Representative BRITISH COLUMBIA LACROSSE ASSOCIATION POLICY NO. CGL/D&O/Property SR007780 Term: March 1, 2016-March 1, 2017 THIS CERTIFICATE IS ISSUED AT THE REQUEST OF: City of City of New Westminster; Douglas College, New Westminster City of Abbotsford North Regional District Alberni Clayoquot Regional District City of North Vancouver; District of North Vancouver Canlan Ice Sports Corp. (Armstrong) North Vancouver Recreation and Culture Commission City of Armstrong, Township of Spallumcheen, Parks & Recreation Commission The Corporation of the District of Oak Bay City of Burnaby; Burnaby Winter Club Town of Oliver City of Campbell River Oliver Parks & Recreation Soceity City of Castlegar Town of Osoyoos Village of Chase City of Parksville City of Chilliwack Village of Pemberton Chief Development Group, Operators of Prospera Centre (Chilliwack) Peninsula Recreation Commission District of Coldstream City of Penticton Regional District, Town of Comox Global Spectrum Facility Management City of Coquitlam City of Port Alberni City of Courtenay City of Port Coquitlam Chesterfield Sports Society (Cowichan) City of Port Moody Regional District and Shawnigan Hills Fields; District of North District of Powell River Cowichan, Municipality of North Cowichan - Evans Park; City of Prince George Cowichan Sportsplex Northern Sport Centre Ltd. (Prince George) City of Cranbrook University of Northern BC (Prince George) Village of Cumberland City of Quesnel City of Dawson Creek City of Revelstoke Corporation of Delta; RG Operations LP City of Richmond District of Elkford Richmond Arenas Community Association City of Enderby Richmond Olympic Oval Township of Esquimalt City of Rossland and the Rossland Arena City of Fernie Capital Regional District (Saanich) City of Fort St. John District of Central Saanich; District of North Saanich Town of Gibsons District of Saanich; Prospect Lake Soccer Club; Lakehill Soccer Association Village of Gold River Pacific Institute for Sport Excellence Town of Golden City of Salmon Arm City of Grand Forks Salmon Arm and Shuswap Lake Agricultural Association - SASCU Indoor District of New Hazelton Memorial Sports Complex; Hassen Multisport Complex Village of Hazelton St. Thomas More Collegiate District of Hope UBC Okanagan District of Houston Shawnigan Lake Community Centre Burrard Indian Band Shuswap Recreation Society Lower Nicola Indian Band Town of Sidney Squamish Nation Indian Band Township of Smithers City of Kamloops Sooke & Electoral Area Parks & Recreation City of , City of West Kelowna; RG Operations General Partner Ltd. District of Sparwood University of British Columbia Okanagan District of Squamish District of West Kelowna Strathcona Regional District City of Kimberley District of Summerland District of Kitimat Sunshine Coast Regional District, District of Sechelt, Town of Gibsons, Gibsons Kwantlen Polytechnic University – Langley, Richmond and Area Community Centre; Shirley Macey, Brothers, Mary Anne West and Town of Ladysmith Cliff Gilker fields in Gibsons; Kinnickinick, Picadilly, and Hackett fields in District of Lake Country Sechelt; Sunshine Coast Arena City of Langford, Performance Plus Hocky Inc. (Langford); City Centre Park City of Surrey Eagle Ridge Community Centre St. Bernadette's Roman Catholic Archbishop of Vancouver (Surrey) Canadian Recreation Excellence (Langley/Aldergrove) Corp. City of Terrace City of Langley, Township of Langley City of Trail The Corporation of the Township of Langley and its elected and appointed City of Vancouver, ils Board of Parks & Recreation & Affiliated Communtity officials, officers, employees, agent and volunteers. Centre Associations & Societies Langley Facilities Society Vancouver Police Board, their Officials, Officers, Employees, Servants & Agents Ten Feet Sports & Entertainment Ltd. (Langley) Canadian Recreation Excellence Corp., Greater Vernon Governance District of Lillooet City of Vernon; Okanagan College (Vernon); Greater Vernon Athletic Park Village of Lumby City of Victoria; L'Ecole Brodeur (Victoria) District of Mackenzie RG Facilities (Victoria) Ltd. (Save On Foods Memorial Centre) Canadian Recreation Excellence (Pitt Meadows) Corp. West Shore Parks & Recreation Society Nustadia Recreation Inc. (Pitt Meadows) District of West Vancouver; Collingwood School City of Pitt Meadows Municipality of Whistler City of Maple Ridge City of White Rock; The City of White Rock Centennial Batting Cages Maple Ridge & Pitt Meadows Parks & Leisure Services Commission City of Williams Lake RG Operations LP (Maple Ridge/Pitt Meadows) The Justice Institute of BC City of Merritt; Merritt Arena Sports Ltd. DND Properties/Colville Baseball Diamond with lights; HER MAJESTY THE District of Mission and the Mission Leisure Centre QUEEN IN RIGHT OF (CANADA) City of , Arbutus Meadows Equestrian Centre Ltd. and Culverden Vancouver School Board Holdings Ltd. BC SCHOOL DISTRICTS Regional District of Nanaimo, Nanaimo Norhetts Rugby Club School District 19 School District 39 School District 60 School District 72 City of Nelson School District 23 School District 40 School District 61 School District 73 Above are added as additional insured, but solely with respect to School District 27 School District 41 School District 62 School District 75 the liability which arises out of the activities of the named insured. School District 33 School District 42 School District 63 School District 79 School District 34 School District 43 School District 67 School District 82 School District 35 School District 44 School District 68 School District 83 School District 36 School District 46 School District 69 School District 93 SPORTS-CAN INSURANCE School District 37 School District 57 School District 70 AUTHORIZED REPRESENTATIVE School District 38 School District 58 School District 71 PLEASE SEND COMPLETED FORM TO: BC Lacrosse Association #101 – 7382 Winston Street

NOTIFICATION OF CLAIM Burnaby, BC V5A 2G9 E-Mail: [email protected] ATHLETICS GROUP DEPARTMENT Fax: (604) 421-9775

Full Name of Insured Person Male/Female Date of Birth D/M/Y

______

If a Minor, give Full Name of Parent or Guardian (Relationship) Your Employer or that of Parent or Guardian

______

Name of Team or League for Which You Were Playing Sport

______

Date of Injury Date First Treated By Dentist (If applicable)

______

Explain, in Detail, How the Accident Occurred?

______

______

Was It During a Practice Period of Playing a League Game? Where Game or Practice was Taking Place

______

Nature of Injury

______

Name of Dentist or Doctor

______

Address Apt. City Province Postal Code

______

What Other Hospital, Medical or Dental Insurance Do You Have?

______

Signature of Insured or Guardian Date Telephone Number

______

Address Apt. City Province Postal Code

______

CERTIFICATE OF TEAM MANAGER OR CLUB EXECUTIVE

Name of Team/League/Association Policy Number or Certificate Number

______

What Sport is Team Engaged In? Was He/She Injured While Playing in a League Game or in a Practice?

______

Was the Above Player a Member At The Time of Injury? On What Date Did He/She Join the Team?

______

Signed State Position in Club Telephone Number

______

Address Apt. City Province Postal Code

______#103-8411 200th Street Tel: (604) 888-0050 Langley, BC V2Y 0E7 Fax: (604) 888-1008

Royal Claims Services Ltd

CLAIM NO: ______

INSURED: ______

NAME: ______(Above office use only) ______

OTHER INSURANCE DECLARATION FORM ______The Accident Policy as purchased by your sports association provides coverage in excess of any private or government medical/dental plan. If you incur medical or dental expense as the result of sports injury, you are required to submit those expenses to your government or private medical dental plan. Only expenses not covered by MSP (the provincial plan for province you reside in) will be considered. Any primary coverage you have in excess of the provincial plan must also be utilized first. If in the event your personal medical/dental plan does not provide full reimbursement, you are then eligible to submit the amounts not paid to your sports association for processing.

Please clarify your situation by checking on of the following:

Yes, I do have private coverage but I do not believe that they will provide full reimbursement and would ask that you keep my claim open until we receive clarification of the amount of the expenses not covered by them, at which time I will forward the amount not covered by them to you for your consideration.

No, I do not maintain any private medical/dental coverage. The expenses I am submitting are not covered by any other primary plan.

If you are a minor, then your parents or legal guardian must complete this form on your behalf.

DATE: ______

NAME: ______(Please Print)

SIGNATURE: ______

THIS FORM IS TO BE SUBMITTED WITH EVERY SPORTS ACCIDENT CLAIM FORM, DULY COMPLETED AND SIGNED.

Royal Claims Services Lt BC Lacrosse Medical Reporting Form (to be completed by physician and returned to patient) Name of Patient: Name of Physician:

Birthdate of Patient Name of Medical Facility:

Patient Address: Address of Physician:

Date of Accident : Date of Initial Exam: Name of Family Doctor: Hospitalization required including date admitted?

Please indicate diagnosis and initial treatment:

Please state if any further treatment required:

Has the patient ever had a comparable or same condition?:

If yes , please indicate when and specify:

Does the patient have any condition that would influence current infirmity?

Physicians Signature : Date:

***Please submit all claims to the BC Lacrosse #101‐7382 Winston Street Burnaby BC V5A 2G9*** Dental Claims Form Name of Patient: Name of Dentist : Patient Address: Address of Dentist:

Service date Procedure Code Tooth Dentist Lab Fee Total I understand that the fees listed in this claim may not DD MM YYYY Code Fee Charges be covered by or may exceed my plan benefits, I understand that I am financially responsible to my dentist for the entire treatment.

Patients Signature:

This is an accurate statement of services performed and the total fee due and pypayable E& OE Office Verification :

Nature of injury, including details : (Dentist Use only)

Further Treatement required. (Pre‐determination) Procedure codes Procedure description Tooth Dentist Lab Fee Total Estimated Timeline Code Fee Charges DD MM YYYY

Additional Treatment Details. (Dentist Use only)

***Please submit all claims to the BC Lacrosse #101‐7382 Winston Street Burnaby BC V5A 2G9***