MYSA Accident Medical Expense Benefits and
Accidental Death and Dismemberment Benefits

Term of Insurance: September 1, 2007 to September 1, 2008

INSURED PERSONS
All registered team members, coaches, managers, referees, officials, and volunteers of the teams, leagues or of the association.

COVERED ACTIVITIES
Insured persons are covered for injuries (or death) resulting directly and independently of all other causes, from accidents occurring while participating in the following covered activities:

• Scheduled games, team practice sessions or sponsored activities, provided they are under the direct supervision of a team official; or sanctioned local or national tournaments as a member of a contestant team.
• Organized, supervised group travel as authorized by the Policyholder directly to and from a covered event.

WHAT IS NOT COVERED
The plan does not provide coverage for: (1) intentionally self-inflicted injury; (2) air travel except as a fare-paying passenger on a regularly scheduled airline on a scheduled flight; (3) injuries resulting from other than Covered Activities; (4) loss resulting from sickness or disease, except bacterial infection which occurs through an accidental wound.

ACCIDENT MEDICAL EXPENSE BENEFITS
For reasonable necessary medical expenses, our Youth Soccer Medical Expense Insurance pays up to $100,000 for injuries sustained in a Covered Accident. Dental injuries are treated like any other injury. Payment will not be made for any expenses incurred after 104 weeks of the accident date. An Expense is considered incurred on the date the Medical Care is rendered. A $500 Deductible and an 80/20 co-insurance applies to each accident.

“Injury” means bodily injury of an Insured Person resulting directly and independently of all other causes from an accident which occurs while he or she is participating in a Covered Activity. Sickness or disease (except pus forming infections which occur through an accidental cut or wound) of any kind will not be considered as bodily injury.

Reasonable Expenses means usual and customary charges.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
The plan pays:

• $5,000 for loss of life, or loss of two or more members which results from injuries sustained in an accident which occurred while participating in a Covered Activity.
• $2,500 for loss of one member (hand, foot or eye), which results from injuries sustained in an accident which occurred while participating in a Covered Activity.
• Such payment shall be in addition to any other indemnity payable to the date of loss, but only one amount, the larger amount applicable shall be payable for all such losses resulting from any one accident.
• “LOSS” shall mean, with respect to hands and feet, physical separation through or above the wrist or ankle joint; with respect to the eyes, entire and irrecoverable loss of sight.

EXCESS COVERAGE
Accident Medical Expense insurance is provided on an “excess” basis. This means that after the insured player or coach has been reimbursed for medical expenses by other insurance programs, and after the deductible has been satisfied, the Youth Soccer Accident Medical Expense plan will pay up to the maximum Medical Expense benefit for remaining treatment, service and supply expenses. These other programs include group, blanket or franchise health insurance coverage, group hospital or medical service plans, and prepayment coverage; any coverage under labor-management trustee plans, union welfare plans, employer organization plans, and coverage under any governmental programs, coverage required or provided by any statute, and automobile reparations insurance (no-fault) coverage.

CLAIM PROCEDURES
For AD&D and Accident Medical Expense Claims, claim forms are available through your State Association, League or Club Offices. Detailed Accident Medical Expense claim instructions can be found on each claim form. In the event of injury requiring medical treatment, you should:

• Fully complete a claim form verified by a witness and submit it to your State Soccer Association for verification.
• Notice of claims must be filed within 30 days from the date of injury.

Youth Soccer Accident Medical coverage is provided on an “excess” basis. Therefore, charges must first be submitted to any other medical insurance carrier available to the participant.

INDOOR SOCCER
The accident medical policy will provide the same benefits for indoor soccer as for outdoor soccer. For coverage to be valid your state association must sanction indoor soccer.

THIS OUTLINE IS ONLY FOR GENERAL INFORMATION AND NONE OF THE ABOVE SHALL AMEND OR ALTER THE INSURANCE CONTRACT. THE WORDING OF THE POLICY CONSTITUTES THE ONLY AGREEMENT BETWEEN THE INSURED AND THE INSURANCE COMPANY. CONSULT YOUR POLICY FOR COVERAGE EXCLUSIONS.

NATIONAL ADMINISTRATOR
Pullen Insurance Services, Inc.
6300 Ridglea Place, Suite 614
Fort Worth, TX 76116
Tel: 817-738-6100
Fax: 817-738-2993
E-mail: ppullen@pullenins.com
Website: www.pullenins.com

• Insurance Claim Form

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MYSA Liability Coverage Outline

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1. Minnesota Youth Soccer Association
2. All affiliate associations, leagues, & clubs.
3. All officers, directors, coaches, employees, official team members, referees, teams, leagues, and volunteers while acting on behalf of Minnesota Youth Soccer Association.

THIS OUTLINE IS ONLY FOR GENERAL INFORMATION AND NONE OF THE ABOVE SHALL AMEND OR ALTER THE INSURANCE CONTRACT. THE WORDING OF THE POLICY CONSTITUTES THE ONLY AGREEMENT BETWEEN THE INSURED AND THE INSURANCE COMPANY. CONSULT YOUR POLICY FOR COVERAGE EXCLUSIONS.

NATIONAL ADMINISTRATOR
Pullen Insurance Services, Inc.
6300 Ridglea Place, Suite 614
Fort Worth, TX 76116
Tel: 817-738-6100
Fax: 817-738-2993
E-mail: ppullen@pullenins.com
Website: www.pullenins.com

• Liability Insurance Certificate Request form