National Sports Insurance

Sports Insurance | Soccer Application

Application



We suggest using your e-mail address as your user name
User Name
Password

E-Mail
Verify E-Mail

Policy Holder (full name of league or team)
Address
City
State
Zip

Contact Name (first and last)
() - Phone
() - Cell

Mailing Address
City
State
Zip

Business Type

Number of years in business


Specified Activities

(0/500)

Effective Date
Current Insurance Company

Have you recently had a liability claim within the last 5 years?
Yes
No



WARNING: READ CAREFULLY!
Each school or studio must install a Release and Waiver of Liability and indemnity Agreement for all students and staff members. Unintentional error on your part in securing Waiver and Release forms shall not void your coverage in the event of any occurrence to a student or staff member. However, your failure to maintain an adequate system to regularly secure Waiver and Release forms shall void your coverage in the event of an occurrence to a student or staff member. A Waiver/Release form will be emailed to your school or studio upon request. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer submits application or files claim containing a false or deceptive statement may be guilty of insurance fraud. The minimum premium on this program is $490.00 which is also the minimum earned. What this means is if you cancel your insurance, the insurance company will keep the minimum premium and not return any portion to you. Any premium amount in excess of the $490.00 minimum may be returned on a prorated basis if you cancel coverage.
I Accept I do not Accept *


Yes No    Do you have a release waiver on file for each student? *
Yes No    If so, are both signatures required for minors? *

Coverage Period

Has any prior coverage been cancelled or not renewed?
Yes
No


Does your organization currently utilize a waiver system?
Yes
No


Does your organization have a risk management plan?
Yes
No


Type of Coverage

Participants


Application Type

Cost Estimate:

Medical Expense Benefits Agreement

If the Covered Person incurs eligible expenses as the direct result of a covered injury and independent of all other causes, the Company will pay the charges incurred for such expense within 365 days, beginning on the date of accident. Payment will be made for eligible expenses in excess of the applicable Deductible Amount, not to exceed the Maximum Medical Benefit. The first such expense must be incurred within 90 days after the date of the accident. “Eligible expense” means charges for the following necessary treatment and service, not to exceed the usual and customary charges in the area where provided.

  • Medical and surgical care by a physician
  • Radiology (X-Rays)
  • Prescription Drugs and medicines
  • Dental Treatment of sound natural teeth
  • Hospital care and service in semi-private accommodations, or as an outpatient
  • Ambulance service from the scene of the accident to the nearest hospital
  • Orthopedic appliances necessary to promote healing

Excess coverage: This plan does not cover treatment or service for which benefits are payable or service is available under any other insurance or medical service plan available to the Covered Person.

Exclusions and Limitations

This plan does not cover any loss to or resulting from:
  • Suicide, self-destruction, attempted self-destruction or intentional self-inflicted injury while sane or insane.
  • War or any act of war, declared or undeclared
  • Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.
  • Voluntarily taking any drug or narcotic unless the drug or narcotic is prescribed by a Physician.
  • Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy.
  • Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder.
  • Injury caused by, contributed to or resulting from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician.
  • Service or Active Duty in the armed forces, National Guard, military, naval or air service or organized reserve corps of any country or international organization.
  • Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an immediate Family member of the Covered Person.
  • Treatment of a hernia, Osgood-Schlatter’s disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, whether or not caused by a Covered Accident.
  • Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy.
  • Eyeglasses, contact lenses, hearing aids.
  • Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from: While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers.

Liability Exclusions

Abuse or molestation, aircraft, all acts of terrorism, asbestos liability, assault and battery, collapse of temporary structure, owner auto coverage, employment related practices, fungi and bacteria, hepatitis, HIV, HTVL, AIDS, transmissible spongiform encephalopathy, lead poisoning, medical payments, nuclear energy liability, professional liability, pyrotechnics activity, total pollution, war liability, and liability for occurrences prior to the effective date of coverage. All of the above are subject to the terms and conditions of the policy.

Note: There is no liability coverage for claims arising out of any of the following activities: All motor sports, ballooning, bungee jumping, cheerleading pyramids, gymnastics, inflatables, luge, mountain climbing, parachuting, polo, rock climbing, rodeo or any equestrian-related sports, sale/manufacture or distribution of any athletic equipment, skin diving, SCUBA diving, snow skiing, squash, tobogganing, use of saunas, white water rafting, water craft, or any saddle animal exposures.

You must accept the terms of our Medical Expense Benefits agreement to continue
I accept the terms of the Medical Expense Benefits agreement
Yes
No
Additional Locations
Do you have any additional locations?
Yes No
Additional Insureds
Do you have any additional insureds?

Yes No
Add a Dance Recital
Would you like to add tournament coverage to your policy?
Yes No
MANDATORY FRAUD WARNING STATEMENTS BY STATE

ARKANSAS, LOUISIANA
"Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."

VIRGINIA, TENNESSEE, MAINE
"It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits."

COLORADO
"It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."

DISTRICT-OF-COLUMBIA
"WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.
In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."

FLORIDA
"Any person who knowingly and with intent to injure, defraud, or deceive any insurer
files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree."

KENTUCKY
"Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals,
for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."

NEW JERSEY
Insurance applications must contain this statement: "Any person who includes
any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties."

NEW MEXICO
"ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS
FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES."

NEW YORK
"Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance or a statement of claim
containing any materially false information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

OHIO:
"Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."

OKLAHOMA
"WARNING: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information is guilty of a felony."

PENNSYLVANIA
Purpose of misleading "Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for
the information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."

I accept the terms I do not accept the terms *
Signature Signature (Typed name indicates signature)
Today’s Date (9-23-2017)
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