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