Mixed Martial Arts Release Form - PDF

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					                         Martial Arts Accident & Liability Insurance

s Martial Arts Schools or Studios
The Accident                             Accidental Death                        • parachuting, except for
                                         and Dismemberment                         self preservation;
Coverage                                 Benefit                                 • bungee jumping, flight in an
$100,000.00 Benefit                                                                ultralight aircraft, hang gliding;
                                         ($50,000.00 Benefit)
(Pays the medical bills of an            If a covered injury results in          • sickness, disease, bodily or mental
injured student or staff member)                                                   infirmity or medical or surgical
                                         any of the losses specified below
                                                                                   treatment thereof, bacterial infec-
Medical Expense                          within 1 year (not applicable in
                                                                                   tion, regardless of how contracted.
                                         Pennsylvania) after the date of
Benefit                                  the accident, the Company will
                                                                                   This does not exclude bacterial
If any youth or adult student                                                      infection that is the natural and
                                         pay the applicable amount:
or staff members incur eligible                                                    foreseeable result of an Injury or
expenses as the direct cause of a        • Full Principal Sum for loss of life     accidental food poisoning;
covered injury and independent           • Full Principal Sum for                • services or treatment rendered
of all other causes, the Company           double dismemberment                    by a Physician, Nurse, or any
will pay the charges incurred for                                                  other person who is:
                                         • Full Principal Sum for
such expense within 1 year begin-          loss of sight of both eyes              – employed or retained by
ning on the date of accident.                                                         the Policyholder; or
Payment will be made for eligible        • 50% of the Principal Sum for
                                           loss of one hand, one foot,             – is the Insured Person or an
expenses in excess of other appli-                                                    Immediate Family Member;
cable insurance, not to exceed the         or sight of one eye
Maximum Medical Expense Benefit          • 25% of the Principal Sum for          • flight in an aircraft, except as
of $100,000.00,subject to a deductible     loss of index finger and thumb          a fare-paying passenger;
of $250.00. The first such expense         of same hand                          • dental treatment, except as
must be incurred within 60 days                                                    otherwise provided, and only
after the date of the accident.          Exclusions                                when Injury occurs to sound
“Eligible expenses” means charges        This plan does not cover any loss         natural teeth;
for the following necessary treat-       to or resulting from:                   • any loss for which benefits are paid
ment and service, not to exceed          • intentional self-inflicted injury,      under state or federal worker’s
the usual and customary charges            suicide while sane or insane or         compensation, employers liability,
in the area where provided.                any attempt thereat (in Missouri        or occupational disease law;
• Medical and surgical care                this applies only while sane);        • treatment in any Veteran
  by a physician                         • voluntary self-administration of        Administration or Federal
                                           any drug or chemical substance          Hospital, except if there is a
• Radiology (X-rays)
                                           not prescribed by, and taken            legal obligation to pay;
• Prescription drugs and medicines         according to the directions of        • cosmetic surgery, except for
• Dental treatment of                      the Insured Person’s Physician;         reconstructive surgery due to
  sound natural teeth                      participation in a riot or              a covered injury;
• Hospital care and service in             insurrection;                         • charges the Insured Person
  semi-private accommodations                                                      would not have to pay if He
                                         • an act of declared or undeclared
  or as an outpatient                      war;                                    did not have insurance;
• Ambulance service from the             • active duty service in any Armed      • eyeglasses, contact lenses,
  scene of the accident to the             Forces of any country, and, in          hearing aids;
  nearest hospital                         such event, the prorata unearned      • charges that are in excess of
• Orthopedic appliances necessary          premium will be returned upon           Usual, Customary, and Reasonable
  to promote healing                       proof of service. This does not         charges.
• Physiotherapy                            include Reserve or National Guard
                                           active duty or training unless it
                                           extends beyond 31 days;

Note: Certain of these exclusions and limitations may be modified to meet individual state requirements.

Payment through Visa, Mastercard or a flexible financing payment plan available upon request.
The Liability                             • Ownership, use, or maintenance
                                            of gyms, fields, or school areas             Premium Rates
Coverage                                  Includes coverage for all youth                Following is the combined
$1,000,000.00 Coverage                    hosted or non-hosted tournaments               Accident and Liability premium
(Protects you in the event of             at no additional charge.                       rate:
a lawsuit or property damage)             Additional insureds such as
                                          landlords can be added at no                   $8.95 Per Student
Who Is Covered                            additional charge.                             Per Year
This $1,000,000.00 occurrence form                                                       (Staff members are included
                                                                                         at no additional charges.)
general liability program provides        Exclusions
protection for your martial arts                                                         Hired and non-owned automobile
                                          Fraudulent or dishonest acts,
school, owners, directors, instructors,                                                  liability coverage may be added
                                          asbestos liability, assault and
and employees against claims of                                                          for an additional $850.00.
                                          battery, punitive or exemplary
bodily injury liability, property         damages, sexual abuse and                      Note: Hired and non-owned auto-
damage liability, personal and            molestation, employment related                mobile liability coverage provides
advertising injury liability, and the     practices, professional liability, total       protection for rented, borrowed
litigation costs to defend against        pollution, collapse of temporary               and other non-owned vehicles
such claims. There is no deductible       structure, fireworks and pyrotech-             driven on martial arts business.
amount for this coverage. Coverage        nics, nuclear energy liability, use
is offered through the Sports and         of saunas, sale/manufacturing/                 An additional $1,000,000.00 of
Recreation Providers Purchasing           distribution of any athletic equip-            liability coverage is available for
Group, pursuant to the Federal Risk       ment, owned auto coverage,                     an additional $1,100.00
Retention Act of 1986.                    medical payments, and liability
                                          for occurrences prior to the effec-            An additional $2,000,000.00 of
                                          tive date of coverage. All of the              liability coverage is available for
Coverage includes suits                                                                  an additional $2,200.00
arising out of:                           above are subject to the terms
                                          and conditions of the policy.
• Injury or death of participants
• Injury or death of spectators           Note: There is no liability coverage
• Injury or death of volunteers           for claims arising out of any of the
                                          following activities: Gymnastics,
• Property damage liability               Cheerleading Pyramids,Trampolines
• Host liquor liability (nonprofit)       or Inflatable Devices, Waterslides,
• General negligence claims               White Water Rafting, Water Craft,
• All activities necessary or             Scuba Diving, Bungee Jumping,
  incidental to conduct activities        Rock Climbing, Repelling, Ballooning,
                                          Parachuting, Rodeo or any other
• Cost of investigation and defense       Saddle Animal Exposures.
  of claims, even if groundless

Cossio Insurance Agency
107Old Laurens Rd.
Simpsonville, SC 29681                     This brochure has been designed to illustrate the highlights of this program but is not a
(864) 688-0121                               contract. Some exclusions and coverages may be modified to meet individual state
FAX (864) 688-0138                                      requirements. For specific details, please view a sample policy.
                                                                          Not Available in All States
Martial Arts Accident & Liability Insurance
                      Participation in today’s Martial        However, now a comprehensive
                      Arts can provide physical fitness,      program has been developed
                      discipline, and entertainment…          to specifically cover the inherent
                      but can also result in accident and     risks involved in running a
                      injury. In the past, accident and       Martial Arts School or Studio.
                      liability coverage for Martial Arts     This Martial Arts Accident and
                      School or Studios was either too        Liability Insurance Program is
                      costly, too limited, or not available   designed to help eliminate the
                      at all. Individuals were either         financial and emotional burden
                      forced to pay extremely high            one can incur as a result of a
                      insurance premiums, or to run           lawsuit or participant injury claim.
                      programs without proper insurance
                      protection; running the risk of
                      personal exposure to lawsuits or
                      a participant’s injury claim.

                      Plan Highlights
                      s Occurrence Form Policy
                      s Flexible Premium Rating

                       Underwritten by:

                                   Aegis Group
                        American Sentinel Insurance Company
                         Aegis Security Insurance Company

                      Cossio Insurance Agency
                      107 Old Laurens Rd • Simpsonville,, SC 29681
                      (864) 688-0121 • FAX (864) 688-0138 • www.cossioinsurance.com
                      Not Available in All States                                     Form: AG MA(BT)2005(2)
           Martial Arts Accident & Liability Insurance Enrollment Form

Please print or type
 1. Name of School or Studio __________________________________________________________________________________

 2. Address_________________________________________________________________________________________________
                                      Street                              City                                       State            Zip

 3. Name of Owner(s) ________________________________________________________________________________________

 4. Desired Effective Date of Coverage_____________________________ Termination Date _____________________________

 5. Are you a
    s Corporation          s Municipality           s Partnership   s Health Club   s Park District     s Individual          s LLC

 6. What styles of Martial Arts are taught? Please be specific. ________________________________________________________

 7. Has your past liability coverage been cancelled in any way in the last three years? If so, please be specific.

 8. Waiver Requirement
    Each school or studio must install a Release and Waiver or 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 an 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 full supply
    of Waiver and Release forms shall be shipped to your school or studio upon request.

 9. Premium Calculation
    Total number of students in the busiest month of the year _________ x $8.95 = $ ___________________________________
                 s Optional hired and non-owned automobile coverage ($850.00) = $ ___________________________________

                 s Optional additional $1,000,000.00 of liability coverage ($1,100.00) = $ ___________________________________
                 s Optional additional $2,000,000.00 of liability coverage ($2,200.00) = $ ___________________________________
                                                                            Total Premium = $ ___________________________________
                                                                                                                     Minimum Premium is $450.00

10. Choose 1 of the following 3 options. Please initial your choice.
     s Enclosed is my check for the Total Premium
     s Please bill my VISA/MasterCard               Card # __________________________________________           Exp. Date _______________
     s Enclosed is 20% of my total premium. I would like to finance my premium.
       Please mail a finance agreement explaining the monthly payment system.

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

     _________________________________________________________________                        ___________________________________
     Signature of School or Studio Representative                                             Policy Holder Telephone Number

     _________________________________________________________________                        ___________________________________
     Agent Name & License Number                                                              Agent Telephone Number

     Agent Address
                                                                                                  Underwritten by:
                             Cossio Insurance Agency   .
                                                                                                                      Aegis Group
                             107 Old Laurens Rd • Sinmpsonville, SC 29681                                  American Sentinel Insurance Company
                             (864) 688-0121 • FAX (864) 688-0138 • www.cossioinsurance.com                  Aegis Security Insurance Company

Description: Mixed Martial Arts Release Form document sample