USPA Accident Insurance Offer for Members of the USPA January 2015 December 2015

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1 USPA Accident Insurance Offer for Members of the USPA January 2015 December 2015 In addition to the Liability Insurance already provided to you as a registered Playing or Student member of the United States Polo Association, Equisure is now offering Accident Insurance to registered members. Accident Policy Benefit Maximums: $100,000 EXCESS Accident Medical Expense $25,000 Emergency Medical Evacuation Benefit* $30,000 Accidental Death & Dismemberment $10,000 Repatriation Expense Benefit* $30,000 Paralysis and Heart & Circulatory Benefit *while travelling 100 or more miles away from $250 per tooth Dental Maximum (per accident) permanent residence $2,500 Deductible (per accident) Coverage applies only while the Covered Person is participating in a Supervised and Sponsored club or USPA event. Please see Accident - Summary of Insurance for additional information and exclusions. Please circle one: RATES: Players (Class I): $50.00 Students/Juniors (Class II): $30.00 Class I: All registered participants of the USPA over the age of 18 Class II: All registered participants of the USPA who are 18 or younger To obtain coverage, registered members must complete this form and mail with check, money order or credit card to: Equisure, Inc, E Rice Pl, Ste 100, Aurora, CO Coverage will not become effective until this completed form and the required premium payment has been received by our office. Name: USPA Member # Mailing Address: City: State: Zip: Please provide address to receive payment receipt. Phone Number: Credit Card #: Exp Date: Security Code (3 digit code on back of card) Card Type: VISA or MasterCard Only (We do not accept Discover or American Express.) Signature: Date: Disclaimer: This coverage is provided by Equisure, Inc in cooperation with the United States Polo Association. This program is not a source of revenue for the USPA. The coverage descriptions in this proposal are abbreviated. You will need to refer to the policy for all terms, conditions, limitations and exclusions. If there is any conflict between the coverage statements within this form and the actual insurance policy, the policy provisions will prevail. Faxed applications are acceptable if paying by credit card. Equisure, Inc E Rice Place, Ste 100, Aurora, CO Phone: Fax

2 Accident - Summary of Insurance For USPA Playing & Student/Junior Members Carrier: QBE Insurance Corporation Policy: NHH Coverage: Applies while the Covered Person is participating in a Supervised and Sponsored club or United States Polo Association event only. Benefits Accidental Death & Dismemberment Benefit Maximum Benefit $30,000 Schedule of Covered Losses: Percentage of Maximum Benefit Loss of Life 100% Both Hands or Both Feet 100% Sight of Both Eyes 100% One Hand and One Foot 100% One Hand and the Sight of one Eye 100% One Foot and the Sight of One Eye 100% Speech and Hearing in Both Ears 100% Quadriplegia 100% One Hand or One Foot 50% The Sight of One Eye 50% Speech or Hearing in Both Ears 50% Paraplegia 50% Hemiplegia 50% Hearing in One Ear 25% Thumb and Index Finger of Same Hand 25% Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of sight of an eye means total and irrecoverable loss of the entire sight in the eye. Loss of hearing in an ear means total and irrecoverable loss of the entire ability to hear in that ear. Loss of speech means total and irrecoverable loss of the entire ability to speak. Loss of a thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits. Paralysis or Paralyzed means total loss of use of a limb. A Physician must determine the loss of use to be complete and irreversible. Quadriplegia means total Paralysis of both upper and both lower limbs. Paraplegia means total Paralysis of both lower limbs or both upper limbs. Hemiplegia means total Paralysis of the upper and lower limbs on one side of the body. If within one year from the date of a covered accident a covered person suffers any of the losses specified, we will pay the benefit amounts listed above. If the same accident causes more than one of these losses, we will pay the largest amount that applies. Accident Medical Expense Benefits Maximum Benefit $100,000 The carrier will pay the usual and customary expenses for eligible expenses that are in excess of benefits paid to the Covered Person by any other health care plan. Such expenses must be incurred for services recommended and approved by a Physician and must be listed under Covered Expenses in the policy s Schedule of Benefits. a) The first such expense must be incurred within 90 days after the date of the covered accident; b) All expenses must be incurred within 52 weeks after the date of covered accident resulting in injury; and, c) The maximum amount payable for all such expenses incurred as the result of any one covered accident will not exceed the maximum benefit amount shown on the policy s Schedule of Benefits. If no other health insurance exists, benefits will be payable like primary coverage. Covered Expenses paid under another Health Care Plan may be used to satisfy the deductible. Any covered expenses payable under the Accident Medical Expense benefit will be reduced by 50 percent if the covered person has HMO or PPO coverage and elects not to use that coverage Covered Expenses include, but are not limited to: 1. Hospital bills, including room and board 2. Emergency room and outpatient treatment 3. Medical or surgical treatment by a licensed doctor 4. Prescription drugs and medicines 5. The services of a licensed or graduate nurse 6. Dental care for injury to sound and natural teeth, up to $250 per tooth 7. Ambulance expenses from the covered accident site to the hospital

3 Medical Evacuation and Transport Expense Benefit The carrier will reimburse covered expenses a Covered Person incurs, as described below, subject to all applicable conditions and exclusions, because he requires emergency medical evacuation or transportation necessitated, directly and independently of all other causes, by a covered accident. The covered accident must occur: 1. while the Covered Person is 100 miles from the Covered Person s Principal Residence; and 2. because adequate medical treatment is not locally available, as determined by the Covered Person s Physician, or because the Covered Person cannot return to his Principal Residence or to a Hospital or other appropriate medical facility with a specified distance of his Principal Residence, using the means of transportation he would have used had the Covered Accident not occurred, as determined by the Covered Person s Physician. Benefits will be payable for: 1. expenses for medical service required for evacuation to the nearest medical facility; 2. expenses for medical service required during transportation to the Covered Person s Principal Residence or to a Hospital; 3. expenses for escort services if the Covered Person is disabled, when a Physician recommends the escort in writing; or expenses for a parent, spouse, sibling or adult child, to escort the Covered Person when a Physician recommends the escort in writing; 4. expenses for ambulance service to the nearest airport and air ambulance upon departure; 5. special costs Incurred while transporting the Covered Person to the nearest adequate medical facility, such as a stretcher, oxygen or other special medical arrangements that a Physician has recommended in writing; 6. expenses for transportation above the cost of a return airfare ticket held by the Covered Person or in the absence of a ticket, the cost of an economy airfare ticket. If services are covered under any workers compensation law, the Covered Person must assign to Us the rights to those benefits. Any expenses that would not have been payable as Covered Expenses under the Accident Medical Expense Benefit will not be payable under this Medical Evacuation Expense Benefit. Other exclusions and limitations that apply to this Benefit are specified in the Common Exclusions section. Repatriation Expense Benefit The carrier will reimburse covered expenses incurred to return a Covered Person s remains to his place of residence in his state, subject to all applicable conditions and exclusions, if a Covered Person s death results, directly and independently of all other causes, from a Covered Accident which occurs 100 miles from the Covered Person s Principal Residence. Covered Expenses mean reasonable costs pre-approved by Us and Incurred for any of the following: embalming or cremation; coffin or urn; transportation of the body or remains; necessary travel expenses of an escort. Necessary travel expenses are limited to reasonable costs of food, hotel room and economy class transportation. Exclusions that apply to this Benefit are specified in the Common Exclusions Section. Principal Residence means the place to which the Covered Person intended to return when he began the trip during which the Covered Accident occurred. Heart and Circulatory Benefit The carrier will reimburse covered expenses incurred for the following Heart and Circulatory conditions: heat exhaustion, heart attack, stroke, burst aneurysm, if: 1. they occur and are manifested during or within 24 hours of a covered activity; and 2. the Covered Person has not attained age 60 on the date he participates in the covered activity; and 3. the Covered Person has neither received nor been advised to have any medical treatment for the condition. We will pay the Loss of Life benefit if the Covered Person dies as a result of a heart and circulatory condition that meets all the requirements described above, within 90 days of taking part in a covered activity. This benefit will terminate at 12:01 A.M. on the day after the team of which the Covered Person is a member has played its last game, including post-season tournament play.

4 Exclusions Benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following: 1. intentionally self-inflicted injury, suicide or any attempted threat while sane or insane; 2. commission or attempt to commit a felony or an assault; commission of or active participation in a riot or insurrection; 3. bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding, 4. declared or undeclared war or act of war; 5. flight in, boarding or alighting from an aircraft, except as a fare-paying passenger on a regularly scheduled commercial or charter airline; 6. travel in or on any off-road motorized vehicle that does not require licensing as a motor vehicle; participation in any motorized race or contest of speed; 7. an accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator s license, unless the covered person holds a valid learner s permit and the covered person is participating in a drivers education program; 8. sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food; 9. travel or activity outside the United States, unless advance written approval is provided; 10. the Covered Person being legally intoxicated as determined according to the laws of the jurisdiction in which the covered accident occurred; voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a physician and taken in accordance with the prescribed dosage; 11. injuries compensable under Workers Compensation law or any similar law; 12. The Covered Person s intoxication as determined according to the laws of the jurisdiction in which the Covered Accident occurred; 13. Benefits will not be paid for any hospital stay that is not considered appropriate treatment for the condition and locality. 14. Overnight Supervised and Sponsored Activities and related travel with duration of 7 days or more are not covered, unless agreed to in writing by the carrier. 15. In addition, benefits will not be paid for services or treatment rendered by any person who is employed or retained by the policyholder or living in the covered person s household or provided by a parent, sibling, spouse or child of either the Covered Person. Accident Medical Benefit Limitations and excluded expenses: 1. cosmetic surgery, except for reconstructive surgery needed as the result of a covered injury; 2. any elective or routine treatment, surgery, health treatment, or examination; 3. blood, blood plasma, or blood storage, except expenses by a hospital for processing or administration of blood; 4. examination or prescription for eyeglasses, contact lenses or hearing aids; 5. treatment in any Veteran s Administration, Federal, or state facility, unless there is a legal obligation to pay; 6. services or treatment provided by persons who do not normally charge for their services, unless there is a legal obligation to pay; 7. rest cures or custodial care; 8. repair or replacement of existing dentures, partial dentures, braces or bridgework; 9. personal services such as television and telephone or transportation; 10. expenses payable by any automobile insurance policy without regard to fault; 11. services or treatment provided by an infirmary operated by the policyholder; 12. treatment of injuries that result over a period of time (such as blisters, tennis elbow, etc.), that are a normal, foreseeable result of participation in the covered activity; 13. treatment or service provided by a private duty nurse; 14. treatment of hernia of any kind; 15. Treatment of injury resulting from a condition that a covered person knew existed on the date of the accident, unless he received a written medical release from his physician.

5 Definitions Ambulatory Medical Center- means a licensed facility providing ambulatory, surgical or medical treatment, other than a Hospital, clinic or Physicians office. Group Travel- means travel authorized by a travel plan that has been officially drawn up and implemented by a participating league or conference. It does not include informal transportation such as that provided by a parent who transports his own child and/or more participants to a covered event without being authorized by the official travel plan. Hospital- means an institution that meets all of the following: 1. it is licensed as a Hospital pursuant to applicable law; 2. it is primarily and continuously engaged in providing medical care and treatment to sick and injured persons; 3. it is managed under the supervision of a staff of medical doctors; 4. it provides 24-hour nursing services by or under the supervision of a graduate registered nurse (R.N.); 5. it has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available on a prearranged basis; 6. it charges for its services. The term Hospital does not include a clinic, facility, or unit of a Hospital for: 1. rehabilitation, convalescent, custodial, or educational or nursing care; 2. the aged, drug addicts or alcoholics; or 3. a Veteran s Administration Hospital or Federal Government Hospitals unless the Covered Person Incurs an expense. Covered Accident- means a sudden, unforeseeable, external event that results, directly and independently of all other causes, in an injury or loss and meets all of the following conditions: 1. occurs while the Covered Person is insured under this Policy; 2. is not contributed to by disease, sickness, or mental or bodily infirmity; and 3. is not otherwise excluded under the terms of this Policy. Physician- means a licensed health care provider practicing within the scope of his license and rendering care and treatment to a Covered Person that is appropriate for the condition and locality and who is not: 1. employed or retained by the Policyholder; or 2. living in the Covered Person s household; or 3. a parent, sibling, spouse or child of the Covered Person. Usual and Customary Charge- means the normal charge, in the absence of insurance, made by the provider of any Appropriate Treatment, but not more than the prevailing charge in the area: 1. for a like service by a provider with similar training or experience; or 2. for a supply that is identical or substantially equivalent. Disclaimer: This is a summary of insurance only and does not guarantee coverage to anyone in possession of this document. The coverage descriptions in this summary are abbreviated. You will need to refer to the policy for complete terms, conditions, limitations and exclusions. If there is any conflict between the coverage statements within this summary and the actual insurance policy, the policy provisions will prevail. To obtain a complete policy, please contact our office.