Autumn Baseball League

Insurance Brochure

CAPE RIPTIDE TRAVEL TEAM
Dr. Laura Bomback Chiropractic
NUTRITION AND HEALTH
9U TEAMS
10U Teams
11U(46/60)
11U(50/70)
12U(60/90)
13U Teams
14U Teams
16U Teams
High School Division
MED. RELEASE FORM
Parent Waiver
Registration form

Accountholder: Autumn Baseball League

293 Linden Street

Fall River, MA 02720

Account Number: T5MP-055300

PLAN OF INSURANCE

Term of Coverage: June 1, 2008 to June 1, 2009

Activity and Dates: June 1, 2008 to November 30, 2008 - Youth Baseball League

Aggregate Limit: None

Eligibility: (100% Participation) All registered participants of the activities sponsored and supervised by the

Accountholder

Effective Date of Individual Insurance:

The effective date of individual insurance shall be the policy date or 12:01am the day following the date notice from the

Accountholder to the Company is postmarked or the date specified by the Accountholder, whichever is later.

Individual Terminations: (General Provision No. 3 applies if this space is left blank):

Change in Coverage: None

Benefits:

Accidental Death & Specific Loss Benefit Provision 6653M

Loss of Life Principal Sum $10,000

Single Dismemberment Principal Sum $5,000

Double Dismemberment Principal Sum $10,000

Loss Period Loss within 180 Days of Injury

Accident Medical Expense: Full Excess Benefit Provision 6425M MO/Amendment Rider 6925M

Maximum Benefit $25,000

Accident Medical Deductible $0

Loss Period Initial treatment received within 30 days of Injury

Benefit Period Benefits payable for 52 weeks from accident date

Dental Expense Benefit

Maximum Benefit Amount U&C per tooth; not to exceed $1,000

Orthopedic Appliances

Maximum Benefit Amount $500

Physical Therapy Expense Benefit

Maximum Benefit Amount $500

The following riders are referenced within or attached to and made a part of this Memorandum of Coverage:

Facility of Payment 6926M

Medical Emergency Services Rider 0JD7M

Speech, Hearing and Language Disorders Benefits Rider 0JR1M

Beneficiary Designation Amendment Rider 9008M

Premiums: $3.80 per participant (age 12 & under), $6.45 per participant (age 13-15), $8.40 per participant

(age 16-18) ...$300.00 minimum premium

This plan has a non-refundable minimum premium of $300 per policy year.

6/18/2008 JS

MEMORANDUM OF COVERAGE

Insurance benefits are underwritten by Mutual of Omaha Insurance Company under Master Policy T5MP-33924 issued to the Direct

Marketer’s Insurance Trust. This Memorandum of Coverage describes the benefits payable under the policy.

PART A. DEFINITIONS

"Ambulatory Surgical Center" means a facility which is licensed as an Ambulatory Surgical Center by the state in which it is located.

"Injuries" means accidental bodily injuries received while the Insured is covered under the policy or certificate which result

independently of sickness and all other causes, in a loss described in the Benefits Provision(s) and Insuring Provision(s) applicable to

such Insured. The Plan of Insurance specifies the Benefit Provision(s) and Insuring Provision(s) applicable to the Insured. Benefits

are payable for an Insured's injuries under only one Insuring Provision for any one accident.

"Intoxicated" means a blood alcohol level which equals or exceeds the legal limit for operating a motor vehicle in the state where the

Injuries occurred.

"Hospital" means a place licensed (if licensing is required by law) as a hospital and operated for the care and treatment of resident

inpatients with a registered graduate nurse always on duty or on call and with a laboratory and an operating room (both on the

premises) where surgical operations are performed by persons legally qualified to do so. In no event shall the term "hospital" mean an

institution or that part of an institution which is used principally as a clinic, convalescent home, rest home, nursing home for the aged,

drug addicts or alcoholics.

"Legally Qualified Physician" means a physician: (a) other than the Insured; (b) practicing within the scope of his or her license; and

(c) recognized as a physician in the state where services are rendered.

"Loss of Eye or Eyes" means the total and irrecoverable loss of the entire sight thereof.

"Loss of Hand or Hands or Foot or Feet" means severance at or above the wrist or ankle joint, respectively.

"Loss of Speech and Hearing" means the total and irrecoverable loss thereof. Loss of hearing that can be corrected by the use of any

hearing aid or device shall not be considered an irrecoverable loss.

"Loss of Thumb and Index Finger of the Same Hand" means severance of two or more entire phalanges of both the thumb and the index

finger.

"Medical Expense" means expense incurred for Medically Necessary services and supplies ordered or prescribed by a Legally Qualified

Physician. Not included are amounts in excess of the Usual and Customary Charges. Medical Expense is incurred on the date the

service or supply is received.

A "Medically Necessary" service or supply means one which: (a) is recommended by the attending Legally Qualified Physician; (b) is

appropriate and consistent with the diagnosis in accord with accepted standards of community practice; and (c) could not have been

omitted without adversely affecting the Insured's condition or the quality of medical care.

"Usual and Customary Charges" means those comparable charges for similar treatment, services and supplies in the geographic area

where treatment is performed.

MC31081 Policy Form T5MP

PART B COVERAGE

The Insured is covered for Injuries received while insured under this provision. Such Injuries must be received while: (a) participating

in activities sponsored and supervised by the Policyholder; (b) traveling to, during or after such activities as a member of a group in

transportation furnished or arranged by the Policyholder.

PART C. BENEFITS

Accidental Death and Dismemberment (Benefit Provision 6653M)

When, because of covered Injuries, the Insured sustains any of the following losses within * See Plan of Insurance * after the date of

the accident, benefits will be paid as follows:

Loss of Life ...................................................................................................................................................................... Principal Sum

Loss of Both Feet, Both Hands or Both Eyes ............................................................................................................. Principal Sum

Loss of One Hand and One Foot ................................................................................................................................. Principal Sum

Loss of One Hand and One Eye or One Foot and One Eye ...................................................................................... Principal Sum

Loss of One Hand, One Foot or One Eye ................................................................................................... One-half Principal Sum

Loss of Speech and Hearing ......................................................................................................................................... Principal Sum

Loss of Speech or Hearing ............................................................................................................................ One-half Principal Sum

Loss of Thumb and Index Finger of the Same Hand ............................................................................ One-fourth Principal Sum

Only one of the amounts shown above (the largest applicable) will be paid for covered Injuries resulting from one accident. The benefit

for loss of: (a) two limbs; (b) both eyes; (c) one limb and one eye; (d) speech and hearing; or (e) thumb and index finger of the same

hand is payable only when such double loss is the result of the same accident.

Accident Medical Expense Benefits (Benefit Provision 6425M MO)

When covered Injuries result in treatment by a Legally Qualified Physician beginning within * See Plan of Insurance *days after the

date of the accident, we will pay the Medical Expense incurred in excess of the Medical Deductible, if any. Benefits shall not exceed the

Usual and Customary Charges. Eligible Medical Expenses are as follows:

(a) Treatment by a Legally Qualified Physician;

(b) Care or services from a Hospital or Ambulatory Surgical Center;

(c) Services from a registered graduate nurse (RN or LPN) not related to the Insured by blood or marriage;

(d) Professional ambulance service;

(e) Orthopedic appliances.

Only covered Medical Expense incurred by the Insured within * See Plan of Insurance * from the date of the accident is covered.

Benefits for any one accident shall not exceed, in the aggregate, the Medical Benefit. The Medical Benefit and Medical Deductible are

specified in the Plan of Insurance.

Benefits are not payable for services and supplies provided by a U.S. military hospital or a Veterans Hospital when the expenses are

connected with armed service related disabilities.

Benefits are only payable for services and supplies provided by a U.S. military hospital when expenses are:

(a) for an armed service retiree; or

(b) for a dependent of an armed service retiree.

Full Excess Coverage (Amendment Rider 6925M)

Benefits for Medical Expense will be paid only for such expense which is not recoverable from any other insurance policy, service

contract or workers' compensation.

PART D. FACILITY OF PAYMENT

(Amendment Rider 6926M)

In consideration of the payment of the premium which is recited in the policy, it is hereby understood and agreed that all or a portion of

any indemnities provided by the policy as a result of medical, surgical, dental, hospital or nursing service may, at our option, and

unless we are requested otherwise in writing not later than the time of filing proof of loss, be paid directly to the hospital or person

rendering such services; but it is not required that the services be rendered by a particular hospital or person.

PART F. EXCLUSIONS AND LIMITATIONS

No coverage is provided for: (a) suicide, attempted suicide or intentionally self-inflicted injury while sane or insane (in Missouri, while

sane only); (b) Injuries caused by an act of declared or undeclared war; (c) Injuries received while in the armed service (upon notice to

us of entry into an armed service, the pro rata premium will be refunded); (d) Injuries received while acting as a pilot or crew member; (e)

Injuries resulting from air travel, except while as a passenger for transportation only; (f) Injuries resulting from the Insured's

engagement in or attempt to commit a felony or being engaged in an illegal occupation; (g) Injuries received while under the influence

of any controlled substance, unless administered on the advice of a Legally Qualified Physician; (h) Injuries received while Intoxicated

as specifically defined in this provision; or (i) Injuries sustained while traveling other than as specifically stated in this provision; (j) the

cost of eyeglasses, contact lenses or examinations for either; (k) the cost of dental treatment, except as specifically provided for Injuries

to sound, natural teeth; (l) Injuries covered by workers' compensation or employer's liability laws; or (m) prescription drugs.

PART G. GENERAL PROVISIONS

1. Individual Terminations: Unless otherwise specified in the Plan of Insurance, the insurance of any Insured will terminate on

whichever of the following dates occurs first: (a) the date the Insured ceases to be within the classes of persons eligible for coverage

under this policy, (b) the date that any premium for the Insured's insurance is due and unpaid or (c) the date this policy terminates.

2. Change in Coverage: Any change in an Insured's coverage because of a change in classification will become effective as

specified in the Plan of Insurance.

3. Reinstatement or Reenrollment: If the insurance of any Insured is terminated for any reason, any insurance subsequently

effected on such Insured either through reinstatement or reenrollment shall apply only to covered loss resulting from covered injuries

sustained after the date of reinstatement or reenrollment, whichever the case may be.

4. Notice of Claim: Written notice of claim must be given to the Company within twenty days after the occurrence or commencement

of any loss covered by the policy, or as soon thereafter as reasonably possible. Notice given by or on behalf of the Insured or the

beneficiary to the Company at Omaha, Nebraska, or to any authorized agent of the Company, with information sufficient to identify the

Insured, shall be deemed notice to the Company.

5. Claim Forms: The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by

it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice the claimant shall be

deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for

filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

6. Proofs of Loss: Written proof of loss must be furnished to the Company at its said office in case of claim for loss for which this

policy provides any periodic payment contingent upon continuing loss within ninety days after the termination of the period for which

the Company is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such

proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time,

provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one

year from the time proof is otherwise required.

7. Time of Payment of Claims: Periodic payment will be made in case of loss of time for which benefits accrue during a period of

more than one month. Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic

payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued

indemnity for loss for which this policy provides periodic payment will be paid at the expiration of each month and any balance

remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

8. Payment of Claims: Indemnity for loss of life of the Insured will be payable in accordance with the beneficiary designation and the

provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or

provision is then effective, such indemnity shall be payable to the estate of the Insured. Any other accrued indemnities unpaid at the

Insured's death may, at the option of the Company, be paid either to such beneficiary or to such estate. All other indemnities will be

payable to the Insured.

If any indemnity of this policy shall be payable to the estate of the Insured, or to an Insured or beneficiary who is a minor or otherwise

not competent to give a valid release, the Company may pay such indemnity, up to an amount not exceeding $1,000.00, to any relative

by blood or connection by marriage of the Insured or beneficiary who is deemed by the Company to be equitably entitled thereto. Any

payment made by the Company in good faith pursuant to this provision shall fully discharge the Company to the extent of such

payment.

9. Physical Examinations and Autopsy: The Company at its own expense shall have the right and opportunity to examine the person

of anyone covered under this policy when and as often as it may reasonably require during the pendency of a claim hereunder and to

make an autopsy in case of death where it is not forbidden by law.

10. Legal Actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after

written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the

expiration of three years after the time written proof of loss is required to be furnished.

11. Change of Beneficiary; Assignment: Unless the Insured makes an irrevocable designation of beneficiary, the right to change of

beneficiary is reserved to the Insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or

assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.

12. Conformity With State Statutes: Any provision of the policy which, on its effective date, is in conflict with the statutes of the

state in which the Policyholder is located on such date is hereby amended to conform to the minimum requirements of such statutes.

Underwritten by Mutual of Omaha Insurance Company Home Office: Omaha, Nebraska

______________________________________________________________________________________________________

_____

Form 0JR1M - 1 - (*)

MEDICAL EMERGENCY SERVICES RIDER

This rider is made a part of your policy or certificate to which it is attached. It is subject to all parts of your policy or certificate not in

conflict with this rider.

Rider Date (January 1, 2001, or the Policy or Certificate Date, whichever is later)

If your policy or certificate provides benefits on an expense incurred basis, then the following applies.

DEFINITION

Medical Emergency means a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity,

including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who

possesses an average knowledge of health and medicine, to result in placing the health of the insured person or another person in

serious jeopardy, serious impairment to body function, serious dysfunction of any body organ or part, or with respect to a pregnant

woman:

(a) when there is inadequate time to effect a safe transfer to another hospital before delivery; or

(b) such transfer may pose a threat to the health or safety of the woman or the unborn child.

BENEFITS

If you or your insured dependent incurs expense for a Medical Emergency, benefits will be paid for transportation expenses and

medical treatment necessary to stabilize the condition.

When confronted with a Medical Emergency which, in the judgement of a prudent layperson, would require pre-hospital emergency

services, the insured person may call any local prehospital emergency medical service system by dialing the emergency telephone

access number 911 or its local equivalent.

Benefits are subject to any policy or certificate maximums, deductible and coinsurance provisions.

NONDUPLICATION OF BENEFITS

No benefits are payable under this rider for that portion of expense for which benefits are payable under the policy or certificate or

another rider attached to it. If benefits are payable under more than one provision, then benefits will be provided only under the

provision providing the greater benefit.

MUTUAL OF OMAHA INSURANCE COMPANY

Corporate Secretary

______________________________________________________________________________________________________

_____

Form 0JR1M - 2 - (*)

SPEECH, HEARING AND LANGUAGE DISORDERS BENEFITS RIDER

This rider is made a part of your policy or certificate to which it is attached. It is subject to all parts of your policy or certificate not in

conflict with this rider.

Rider Date (March 21, 2001, or the Policy Date or Certificate Date, whichever is later)

If your policy or certificate provides benefits on an expense incurred basis, then the following applies.

BENEFITS

Coverage will be provided for the medically necessary diagnosis and treatment of speech, hearing and language disorders provided by

a licensed speech-language pathologist or audiologist.

Benefits are subject to any policy or certificate maximums, deductible and coinsurance provisions.

CONDITION

Coverage will be provided only when services are provided in a:

(a) Hospital;

(b) clinic; or

(c) private office.

EXCEPTION

Coverage does not extend to the diagnosis or treatment of speech, language and hearing disorders in a school-based setting.

NONDUPLICATION OF BENEFITS

No benefits are payable under this rider for that portion of expense for which benefits are payable under the policy or certificate or

another rider attached to it. If benefits are payable under more than one provision, then benefits will be provided only under the

provision providing the greater benefit.

MUTUAL OF OMAHA INSURANCE COMPANY

Corporate Secretary

Form 9008M

BENEFICIARY DESIGNATION AMENDMENT RIDER

This rider applies only to the class or classes of Insured specified in the Plan of Insurance.

This rider is made a part of the policy or certificate to which it is attached and is subject to all the terms of the policy or certificate which

are not in conflict with this rider.

Rider Date (same as Policy Date or Certificate Date if no date is shown)

Part A. Definitions

The definitions in the policy, certificate, Insurance Provisions(s) and Benefit Provision(s) apply to this rider.

Part B. Amendment

The General Provision captioned Payment of Claims is hereby deleted in its entirety and the following is substituted.

Payment of Claims: Indemnity for loss of life will be payable in accord with the beneficiary designation made in writing by the Insured

and on file with the Company. In the absence of such beneficiary designation, or in the event the designated beneficiary predeceases

the Insured, indemnity for loss of life will be paid to the first of the following surviving beneficiaries: the Insured’s:

(a) lawful spouse; (b) child or children, jointly; (c) parents, jointly if both are living, or the surviving parent if only one survives;

(d) brothers and sisters, jointly; (e) estate. Any other accrued indemnities unpaid at the Insured’s death may, at Our option, be paid

either to the Insured’s beneficiary or to his or her estate. All other indemnities will be payable to the Insured.

Part C. Exclusions and Limitations

This rider is subject to the Exclusions and Limitations of the Insurance Provision(s) and Benefit Provision(s) applicable to the Insured.

MUTUAL OF OMAHA INSURANCE COMPANY

Corporate Secretary

MUTUAL OF OMAHA

PRIVACY NOTICE - PERSONAL INFORMATION

This Privacy Notice applies to the Personal Information

of customers of the Mutual of Omaha companies. The

companies include:

Mutual of Omaha Insurance Company

Mutual of Omaha Investor Services, Inc.

Mutual of Omaha Marketing Corporation

United of Omaha Life Insurance Company

United World Life Insurance Company

Companion Life Insurance Company

Omaha Property and Casualty Insurance

Company

This Notice applies to our current as well as former

customers.

Why You Are Receiving This Notice

The federal Financial Services Modernization Act and

state privacy laws require us to send you an annual

Notice. This Notice describes how we collect, use, and

protect the Personal Information you entrust to us.

If you have a policy that is covered by the HIPAA

Privacy regulations, you received a privacy notice that

relates to the privacy of your medical information. To

obtain an additional copy of the privacy notice related to

your medical information you can log onto our company's

website:

http://www.mutualofomaha.com/hipaa.html

or you can contact us at:

Mutual of Omaha Insurance Company

Attn: Privacy Office

Mutual of Omaha Plaza

Omaha, NE 68175-1029

Personal Information

Personal Information means information that we

collect about you, such as name, address, Social Security

number, income, marital status, employment and similar

personal information.

Information We Collect

In the normal course of business we may collect

Personal Information about you from:

Applications or other forms we receive

from you.

Your transactions with us, such as your payment

history.

Your transactions with other companies.

Other sources (such as motor vehicle reports,

government agencies and medical information

bureaus).

Consumer-reporting agencies.

Information We Share

In the normal course of business we may share your

Personal Information among the Mutual of Omaha

companies. Depending on the products you have with

us, the type of information we share could include:

Your name.

Your income.

Your Social Security number.

Other identifying information you give us.

Your transactions with us, such as your payment

history.

We do not share Personal Information with third parties

outside of the Mutual of Omaha companies except as

required or permitted by law.

How We Protect Your Information

We restrict access to your Personal Information. It is

given only to the employees of Mutual of Omaha and

others who need to know the information to provide our

insurance or financial services to you.

We have physical, electronic and procedural safeguards

in place to make sure your Personal Information is

protected. These safeguards follow legal standards and

established security standards and procedures.

MC30684_0108