Amateur Teams / Leagues Online Application
Verification of Coverage
Application Receipt Date / Time:
07/15/2013 11:03:10 PM - entered by
Customer
I. GENERAL INFORMATION
Application ID: 86255
Application Status: Complete
Named Insured: Tri-State Home School Athletic Association
Doing Business As:
Type of Organization: association
Form of Business: not-profit
Contact's Name: Kevin Kirkman
Primary Location Address: 6589 W Pagosa Place
Address 2:
City: Fayetteville
State: AR
County:
Postal / Zip Code: 72704
Home Phone: (479) 409-1932
Business Phone: (479) 409-1932
Fax:
Email Address: kevinpkirkman@gmail.com
Website: www.tshsaa.org
How did you find out about Sadler & Company: Already buy from Sadler
Do your Property Owners or Sponsors require a Certificate Of Insurance? No
Are you seeking coverage for all participants within your organization? Yes
Do any of your teams include both youth athletes (Class B sports) and adult athletes (Class A sports) participating together on the same team? No
Online Agreement and Warranty Statement accepted? Yes
Are you responsible for the ownership, operation or maintenance of a facility or field? No
Are you a municipality or a park and recreation division? No
Do you meet the requirements by not answering Yes to any of the following? Yes
Is there any form of player compensation or prize money awarded for participation? | Are you a school sanctioned sports team or league? | Are any of your activities held on private residential property? | Does the named insured own, operate or maintain any pools? | Are you a gymnastics, martial arts, cheer or dance school? | Are you a member of American Amateur Baseball Congress? | Are you a member of Babe Ruth Baseball or Babe Ruth Softball? | Are you a member of U.S. Youth Soccer Association
Notes:
Organization Affiliation: No Affiliation
II. AGENT INFORMATION
Agency Name: Kevin Kirkman
License Agent Name: Kevin Kirkman
Person Completing Application: Kevin Kirkman
Primary Location Address: 6589 W Pagosa Place
Address 2:
City: Fayetteville
State: AR
Postal / Zip Code: 72704
Phone: (479) 409-1932
Fax:
Email Address: kevinpkirkman@gmail.com
III. MEDICAL PAYMENTS TO PARTICIPANTS / GENERAL LIABILITY INSURANCE
Nationwide Mutual Insurance Company
Policy Number RPG53816
Effective Date 11:03PM ET 07/15/2013
Expiration Date 12:01AM ET 07/15/2014
COVERAGE EFFECTIVE DATE: Coverage begins the exact time and date that this electronic application and internet check is received at Sadler & Company or a future effective date if requested, whichever is later and continues for one full year from the effective date.
| Limits | $250,000 Medical Payments to Participants / $2,000,000 General Liability |
| Medical Payments to Participants Deductible | $100.00 |
| Medical Payments to Participants Plan | Full Excess |
Sports / Participants
| Sports | Age Groups | # of Participants | Totals |
|---|
| Basketball | 12 & Under | 30 | $268.80 ($8.96 per participant) |
| Basketball | 13-15 | 20 | $217.40 ($10.87 per participant) |
| Basketball | 16-19 | 10 | $216.60 ($21.66 per participant) |
| Totals | $702.80 ($702.8 min. premium) |
| Limits |
(minimum premium charges may apply) |
Charges |
| |
$250,000 Medical Payments to Participants / $2,000,000 General Liability |
$702.80 |
| |
24hr Premises Liability Coverage (Not Covered Unless Premium Accepted - Subject to Underwriting Approval) |
$0.00 |
| $2,000,000 |
Optional Coverage: Directors & Officers Liability |
$450.00 |
| State Surplus Lines Tax/Surcharge |
$0.00 |
|
Optional Coverage: Crime |
Not Covered |
| State Surplus Lines Tax/Surcharge |
$0.00 |
| $0 |
Optional Coverage: Equipment |
Not Covered |
| State Surplus Lines Tax/Surcharge |
$0.00 |
| |
NSLPA Membership Fee |
$0.00 |
| FL. 1.3% Hurricane Catastrophe Fund Assessment Fee |
$0.00 |
| Annual Risk Purchasing Group Membership Fee (required) |
$10.00 |
IV. 24HR PREMISES LIABILITY COVERAGE
Do you meet the requirements by not falling under any of the following? No
You are a school sanctioned sports team or league. | You are a gymnastics, martial arts, cheer or dance studio or gym. | You are a municipality or a park and recreation division. | Your organization has activities held on private residential property. | You own, operate or maintain a pool/pool on the outdoor premises for which you are applying for this coverage.
Number of Fields: 0
Number of Acres for Athletic Fields: 0
Location of the fields
Primary Location Address:
Address 2:
City:
State:
Postal / Zip Code:
V. CERTIFICATES OF INSURANCE
The certificate holder is added as an additional insured, but only with respect to the liability arising out of the operations of the insured above.
VI. OPTIONAL COVERAGES
Philadelphia Indemnity Insurance Company
In Lousiana Only: Philadelphia Insurance Company
Optional Coverages are effective only upon final underwriting and acceptance by Philadelphia Insurance Companies. If effective, all Optional Coverages expire one year after effective date.
Directors & Officers Liability ($2,000,000 limit, $1,000 deductible)
Policy Number: PHSADLR131910
Effective Date: 07/18/2013
Did your sports organization purchase a D & O Policy LAST YEAR from an insurance agency OTHER THAN Sadler & Company? No
Has there been any claim made, or is there any now pending , against any corporation or persons proposed for this insurance? No
details:
Does any corporation, director, officer or any other person proposed for this insurance have any knowledge or information of any breech of duty, error, misstatement, misleading misstatement or omission, which could rise to a claim against them? No
details:
Has any corporation, director, officer or any persons proposed for this insurance been the subject of any suit, inquiry, complaint or Notice of Hearing, including, but not limited to, suits, inquiries, complaints or Notice of Hearing based upon or arising from charges of discrimination, sexual harassment or wrongful termination? If so, give details: No
details:
Premium Accepted:
$450.00
Taxes:
$0.00
Notes:
Crime Insurance - NOT APPLIED FOR
Equipment Coverage - NOT APPLIED FOR
Summary of Declined Optionals
VII. POLICY PERIOD CHANGES
| Date | Approved | Effective Date | Change |
| 11/20/2013 11:18 AM | Yes |
11/20/2013 11:18 AM | Add COI:
John Brown University - Property Owner/Lessor - 2000 West University - - Siloam Springs, AR 72761 - Approval Status: Approved |