40007-262701-2.pdf

Gallagher Student Health & Special Risk

©2021 Arthur J. Gallagher & Co. All rights reserved.

Baton Rouge Community College

Premium Quotation 2025-2026 Premium

Basic Athletic Accident Insurance

$25,000 per Injury Maximum $500 per Injury Deductible

Insurance Carrier 2025 – 2026 Annual Premium

Guaranteed Trust Life $67,772 (Flat Renewal)

Catastrophic Athletic Accident Insurance $5,000,000 per Injury Maximum

$25,000 Deductible per Injury Lifetime Benefit Period

Insurance Carrier 2025 – 2026 Annual Premium

Zurich $6,160 (Flat Renewal)

Athletic Census

Sport Men Women

Baseball 37 -

Basketball 21 14

Softball - 21

NOTE: The information contained in this proposal is only an outline of the benefits offered. It is NOT a complete explanation of the policy provisions or specifics of the policy benefits. No coverage is extended via this proposal and no representations are made other than what is stated in the policy. To review a complete description of the program coverage, exclusions, and benefits, please contact us for a specimen copy of the policy.

Schedule of Benefits - Basic

Accident Medical Expense Maximum $25,000 per Intercollegiate Sports Injury

Insured’s

All active registered student athletes, student coaches, student managers and student athletic trainers whose names are on file with the policyholder, for whom premium has been paid.

Covered Activities

Coverage is provided for all participants of the policyholder who are members of a covered team sport in a scheduled game, official tournament game, or practice session authorized, organized or directly supervised by the policyholder; and who are traveling as a team directly to or from such game or practice session.

Deductible1 $500 per Injury

Coinsurance2 100% of Usual and Customary charges after the deductible

Benefit Period 156 weeks from the original date of injury

Accidental Death and Dismemberment $10,000 per occurrence

First Medical Treatment (Includes treatment provided by Student Health Service or Athletic Trainers.)

Within 120 days of the injury to trigger the claim to be eligible under the policy

HMO/PPO Denial Coverage3 Included

Pre-existing Condition Coverage4 Included

Expanded Medical Coverage Included

Heart & Circulatory Coverage5 Included

Accidental Dental Benefit Included; Injury to Sound & Natural Teeth

1 A coordinating deductible allows for the deductible to be met if the student’s primary insurance has reimbursed eligible medical claims above the deductible amount.

2 Eligible expenses include: medically necessary treatment up to the “Usual and Customary” charge.

3 Benefits will be paid on primary basis if the athlete is denied benefits by a HMO/PPO due to failure to follow any required pre-certification or other managed care procedures. A written denial of benefit is required.

4 Pre-existing conditions are covered only if a student was initially cleared by a team physician to participate in a sport.

5 Cardiovascular Accident such as heat exhaustion, strokes or other traumatic events caused by exertion are covered. Cardiovascular testing is covered as a result of the accident; cardiovascular screenings are not covered.

Schedule of Benefits – Catastrophic (Full Excess 1 ) Accident Medical Benefit Maximum $5,000,000 per Injury

Eligibility

All student athletes, student managers and student trainers who are participating in all sanctioned and officially recognized intercollegiate Policyholder sports including all guest recruits of the Participating School’s athletic department who are participating in activities which are on campus and supervised by the Participating School’s athletic department.

Covered Activities

Coverage is provided for participation in scheduled intercollegiate games, supervised practice sessions and during authorized team or individual travel that is paid for or reimbursed by the Participating School in connection with such games or practice sessions.

Coverage is also provided for authorized and supervised conditioning that directly contributes towards the Insured Person’s ability to participate as a player on an intercollegiate team and takes place at the school’s athletic facilities or another facility specifically authorized by the school. For guest recruits coverage is provided for participation in intercollegiate scheduled games and supervised practice sessions which are on campus and for which the guest was invited.

Aggregate Limit of Indemnity2 $5,000,000 Benefit Period The sooner of the Date of Recovery or Lifetime Deductible3 $25,000 Deductible Establishment Period 2 years Benefit Percentage 100% of U&C Medically Necessary Hospital Inpatient Services and Supplies Included in Medical Maximum

Extended Care Facility Confinement $365,000 per calendar year

Daily Room & Board Limit Private or Semi-Private Room Intensive Care

Average Semi-Private Room Rate Reasonable & Customary Charges

Combined Home Health Care & Custodial Care $100,000 per calendar year Treatment of Mental Disorders $50 per visit, 1 visit per day, 50 visits per year Chiropractic/Spinal Manipulation Benefit $1,000 per calendar year Outpatient Physical Therapy Benefits $50,000 per calendar year Accidental Death & Dismemberment $10,000 Heart or Circulatory Death Benefit $10,000 Total Disability Benefit $1,500 per month (4% increase after first 12 Months) Partial Disability Benefit $1,000 per month (4% increase after first 12 Months) Adjustment Expense $40,000 Special Expense Benefit $125,000 College Education Benefit $60,000

1 This insurance is excess over any other valid and collectible insurance program or similar benefit program available to the Insured Person.

2 This is the maximum amount of liability the insurance company has for an Insured Person for all benefits under the plan of insurance due to any one

Accident.

3 Eligible medical expenses under any other insurance policy or service contract will be used to satisfy or reduce the Covered Accident Deductible.

4 Texas – there are no internal benefit limitations. Benefits are payable to the medical maximum.

Exclusions and Limitations - Basic

• Treatment, services or supplies which:

· Are not Medically Necessary;

· Are not prescribed by a Doctor as necessary to treat an Injury;

· Are determined to be Experimental/Investigational in nature;

· Are received without charge or legal obligation to pay;

· Are received from persons employed or retained by the Policyholder or any Family Member, unless otherwise specified; or

· Are not specifically listed as Covered Charges in the Policy

• Intentionally self-inflicted Injury

• Injury received while violating or attempting to violate any duly enacted law

• Injury by acts of war, whether declared or not

• Injury covered by Worker’s Compensation or the Occupational Disease Law

• Treatment of Osgood-Schlatter's disease; appendicitis; osteomyelitis; pathological fractures; congenital weakness; TMJ;

fainting; headaches; boils; detached retina unless directly caused by Injury; Mental or Nervous Disorders whether or not caused by Injury

• Suicide or attempted suicide, or self-destruction or an attempt to self-destroy while insane

• Charges incurred for the use of orthotics unless used exclusively to promote healing

• Dental treatment, except as specifically stated

• Routine eye exams

• Injury sustained fighting, except as an innocent victim

• Injury sustained while committing or attempting to commit a felony

• Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs

• Loss resulting from the use of any drug or agent classified as narcotic, psycholytic, psychedelic, hallucinogenic, or having a similar classification or effect, unless prescribed by a Doctor

• Cosmetic or plastic surgery, except for reconstructive surgery on an injured part of the body

• Injury resulting from participation in or practice for any activity which is not supervised and sponsored by the Policyholder or school

• Treatment of illness, disease, or infections, except infections which result from an accidental injury or infections which results from accidental, involuntary or unintentional ingestion of a contaminated substance

• Charges for treatments, services or supplies which exceed reasonable and customary charges

• Losses directly or indirectly arising out any chemical or biological release and/or contamination which results from Terrorist Activity

• Any loss as the result of Terrorist Activity and/or non-detonating weapons of mass destruction

• Any loss directly or indirectly arising out of any nuclear explosion, detonation, release and/or contamination whether in time of peace or war, and regardless of any other causes or events contributing concurrently or in any other sequence thereto

Exclusions and Limitations - Catastrophic

Zurich American Insurance Company

GENERAL EXCLUSIONS

A loss will not be a Covered Loss if it is caused by, contributed to, or results from:

1. suicide or intentionally self-inflicted injury or any attempt at intentionally self-inflicted injury.

2. war or any act of war, whether declared or undeclared.

3. involvement in any type of active military service.

4. illness or disease, regardless of how contracted; medical or surgical treatment of illness or disease; or complications following the surgical treatment of illness or disease; except for Accidental ingestion of contaminated foods.

5. participation in the commission or attempted commission of a any felony.

6. being intoxicated.

a. An Insured will be conclusively presumed to be intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the locale in which the Accident occurred, to be intoxicated, if operating a motor vehicle.

b. An autopsy report from a licensed medical examiner, law enforcement officer reports, or similar items will be considered proof of the Insured's intoxication.

7. being under the influence of any prescription drug, controlled substance, or hallucinogen, unless such prescription drug, controlled substance, or hallucinogen was prescribed by a Physician and taken in accordance with the prescribed dosage.

8. travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled charter or commercial flight.

9. any condition for which the Insured is entitled to benefits under any Workers' Compensation Act, No Fault Auto Coverage or similar law, only to the extent that losses are the liability of the Insured, the employer, or the workers compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act

10. the Insured riding in or driving any type of motor vehicle as part of a speed contest or scheduled race, including testing such vehicle on a track, speedway or proving ground.

AME EXCLUSIONS

In addition to the General Exclusions listed above, we will not cover expenses under the AME benefit for:

1. Violating or attempting to violate the law; including taking part in any illegal occupation.

2. Fighting or brawling except in self-defense.

3. Bacterial infections, sickness or disease of any kind such as strep throat or tonsillitis, sunburn, frostbite, allergic reactions, except those that occur as a result of accidental ingestion or pus forming infections which occur through an accidental cut or wound;

4. Vegetation poisoning such as poison ivy or poison sumac, or ptomaine poisoning.

5. Reinjury of the same body part within 6 months of the Covered Accident unless previously cleared by a Physician to practice or play.

6. Cosmetic, plastic or restorative surgery unless Medically Necessary for the treatment of the Covered Injury.

7. Any medical expenses related to pregnancy unless Medically Necessary for the treatment of the Covered Injury.

8. Covered Injury for which the Insured is paid benefits under any Workers Compensation Act or similar law, only to the extent that losses are the liability of the Insured, the employer or the workers compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act.

9. Personal comfort or convenience items, such as but not limited to Hospital telephone charges, television rental, guest meals, or internet charges.

10. Treatment by any immediate family member or member of the Insured's household.

11. Expenses incurred for dental care, treatment including dental implants, repair or replacement of sound natural teeth unless Medically Necessary for the treatment of the Covered Injury.

12. Expenses incurred for eye examinations, contact lenses or the fitting, repair or replacement of these items unless Medically Necessary for the treatment of the Covered Injury.

13. Routine physical examinations and related medical services, elective treatment or surgery or experimental or investigative treatments or procedures.

14. Expenses which the Insured is not legally obligated to pay.

15. Expenses for Custodial Services or services provided by a private duty nurse unless such expenses are incurred as a result of a Covered Injury, as prescribed by a Physician.

16. Expenses related to the repair or replacement of existing artificial limbs, eyes, or other prosthetic appliances, or rental of existing medical equipment unless for the purpose of modifying the item because the Covered Injury has caused further impairment of the underlying bodily condition.