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.