INVITATION TO BID

Bid Number: 262701 Bid Title: Sports Insurance Bids will be accepted until July 23, 2026, at 12:00 P.M. CST

Bids Will Be Publicly Opened: July 23, 2026, at 2:00 P.M. CST

Bid Release Date: July 8, 2026

INSTRUCTION TO BIDDERS

It is the bidder’s responsibility to read entire bid including contractor’s license requirements.

INSTRUCTION TO BIDDERS

1. Bids will be accepted until July 23, at 12:00 p.m. To ensure consideration of your Bid, all Bid Packages and addenda shall be returned in an envelope or package clearly marked with Baton Rouge Community College, Bid title, Bid opening date and the Bid number and submitted in person to the following drop off location: The Mail Bag, 7515 Jefferson Highway #326, Baton Rouge, LA 70806. FAXED OR EMAILED BIDS WILL NOT BE ACCEPTED.

2. Baton Rouge Community College (BRCC) will open all timely submitted sealed bids at its office located at Magnolia Library Building, Dumas Room, 201 Community College Drive, Baton Rouge, LA 70806, on July 23, 2026, at 2:00 p.m., in response to this Invitation to Bid. At 2:00 p.m., all Bids will be publicly opened and read aloud.

3. All bid prices and information shall be typed or written in ink. Any corrections, erasures, or other forms of alteration to prices should be initialed by the Bidder.

4. Payment will be made within thirty (30) days after receipt of invoice, delivery, and authorized inspection and acceptance, whichever occurs last. Delinquent payment penalties are mandated and governed by Louisiana R.S. 39:1695.

5. Bids submitted are subject to provisions of the laws of the State of Louisiana including, but not limited to, La. Title 39: 1551-1736, Chapter 17; Purchasing Rules and Regulations (Title 34 of the Louisiana Administrative Code); Executive Orders; and the terms conditions, and specifications listed in this solicitation.

6. Bids shall be signed by a person authorized to bind the vendor in accordance with L.R.S. 39:1594.

7. By signing this Invitation to Bid, the Bidder certifies compliance with all Instructions to Bidders, terms, conditions, and specifications and further certifies that this Bid is made without collusion or fraud.

8. By signing and submitting any bid for $25,000 or more, the bidder certifies that their company, any subcontractors, or principals are not suspended or debarred by the General Services Administration (GSA) in accordance with the requirements in “Audit Requirements in Subpart F of the Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards” (Formerly OMB Circular A-133). A list of parties who have been suspended or debarred can be viewed at www.sam.gov .

Signature of Authorized Bidder:

(Shall be signed and dated) Company:

(Typed or printed)

Name

(Typed Or Printed) Address:

City, State, Zip

Payment Terms:

Telephone No.

Email Address:

Fax No.

STANDARD TERMS AND CONDITIONS

1. Bid form.

All written Bids shall be submitted on the Bid Forms provided and in accordance with the Bid package and properly signed. Bids submitted in the following manner will not be accepted:

A. Bid Instructions and Bid Forms contain no signature indicating intent to be bound;

B. Bid filled out in pencil;

C. Bid not submitted on BRCC’s standard Bid Package and Bid Form.

D. Telegraphic or facsimile bids.

2. Receipt of Bids.

Bids shall be received at the address specified in this Invitation prior to Bid opening time in order to be considered. Entire Bid Packages shall be returned. Bidder is solely responsible for ensuring that its courier service provider makes inside deliveries to the physical location specified. BRCC is not responsible for any delays caused by the bidder’s chosen means of bid delivery. BRCC is not responsible for late deliveries that make use of BRCC’s interoffice mail service.

3. Bid Opening.

Bidders may attend the Bid opening, but no information or opinions concerning the ultimate contract award will be given at the Bid opening or during the evaluation process. Bids may be examined within 72 hours after Bid opening. Information pertaining to completed files may be secured by visiting the BRCC Purchasing Department during normal working hours. Unsuccessful bidders submitting a response to the solicitation will be provided with a copy of the tabulated results by providing a self-addressed stamped envelope with the original bid package.

4. Withdrawal of Bids.

A bidder may only withdraw a bid within forty-eight (48) hours after a bid opening, excluding Saturdays, Sundays and legal holidays, for good cause as for patently obvious, unintentional, and substantial mechanical, clerical, or mathematical errors, or errors of unintentional omission of a substantial quantity of work, labor, material or services made directly in the compilation of the bide.

5. Standards of Quality.

Any product or services bid shall conform to all applicable federal and state laws and regulations and the specifications contained in the solicitation. Objections to the specifications or bid conditions shall be filed in writing and received by the BRCC Purchasing Department at least five (5) days prior to the date of the bid opening.

6. Contract Period The contract is for a period of twelve (12) months beginning August 15, 2026, and ending August 14, 2027. Upon agreement of BRCC and the contractor, a term contract may be extended for two (2) additional twelve-month periods at the same prices, terms and conditions. In such cases, the total contract cannot exceed thirty-six (36) months.

7. Prices & Delivery.

Unless otherwise specified by BRCC in the Invitation, bid prices shall be complete, including transportation prepaid by Bidder to destination and firm for acceptance for a minimum of 45 days. Prices are to be bid on unit of measure requested, per roll, per reel, per carton, per gallon, etc., as specified in the Invitation. If accepted, prices shall be firm for the contractual period.

Bids other than Platform Delivery F.O.B. destination may be rejected. Platform Delivery FOB Destination means the successful bidder shall deliver and unload purchased items to the dock of the designated point of receipt. All cartage, drayage, packaging, handling, palletizing, etc. shall be included in the Bid price. Include a packaging list that includes the purchase order number with each shipment.

Bids may be rejected if the delivery time indicated is longer than that specified in the Invitation.

8. Taxes.

Vendor is responsible for including all applicable taxes in the Bid Price. BRCC is exempt from all state and local sales and use taxes.

9. Award.

A purchase order or contract will be awarded to the Bidder who has provided a responsive and responsible Bid at the most favorable Bid Price as determined by the signed Bid Form.

BRCC reserves the right to award items separately, grouped or on an all-or-none basis and to reject any or all Bids and waive any informalities. The purchase order or contract, faxed, mailed, or delivered to the successful bidder is the official authorization to render services.

10. Invoices.

Invoices shall be mailed to Baton Rouge Community College, Accounts Payable, 201 Community College Drive, Baton Rouge, Louisiana, 70806 or forwarded by email to accountspayable@mybrcc.edu. The invoice shall refer to the delivery ticket number, delivery date, purchase order number, quantity, unit price, and delivery point. A separate invoice for each order delivered and accepted shall be submitted by the contractor in duplicate. Invoices shall show the amount of any cash discount and shall be submitted on the contractor’s own invoice form. Payment will be made on the basis of the unit price as listed in the purchase order/contract. Such price and payment will constitute full compensation for furnishing and delivering the contract commodities or services. Invoice pricing must match bid pricing structure.

11. Purchase Order/Contract Cancellation for Cause.

BRCC has the right to cancel any contract, in accordance with its purchasing rules and regulations, for cause, including but not limited to, the following:

(1) Failure to deliver within the time specified in the contract;

(2) Failure of the product or service to meet specifications, conform to sample quality or to be delivered in good condition;

(3) Misrepresentation by the contractor;

(4) Fraud, collusion, conspiracy or other unlawful means of obtaining any contract with BRCC;

(5) Conflict of contract provisions with constitutional or statutory provisions of state or federal law;

(6) Any other breach of contract.

12. Termination of the Purchase Order/Contract.

Termination for Convenience: BRCC may terminate the contract at any time by giving thirty (30) days’ written notice to the Contractor of such termination or by negotiating with the Contractor an effective date. The Contractor shall be entitled to payment for deliverables in progress, to the extent work has been performed satisfactorily.

Termination for Cause: The State may terminate this contract for cause based upon the failure of the Contractor to comply with the terms and/or conditions of this contract; provided that the State shall give the Contractor written notice specifying the Contractor's failure. If within 15 days after receipt of such notice, the Contractor shall not have either corrected such failure and thereafter proceeded diligently to complete such correction, then the State, may at its option, place the Contractor in default and this contract shall terminate on the date specified in such notice. The Contractor may exercise any rights available to it under Louisiana law to terminate for cause upon the failure of the State to comply with the terms and conditions of this contract; provided that the Contractor shall give the State written notice specifying the State's failure.

13. Termination for Non-Appropriation of Funds.

The continuance of the contract is contingent upon the appropriation of funds to fulfill the requirements of the contract by legislature. If the legislature fails to appropriate sufficient monies to provide for the continuation of the contract, or if such appropriation is reduced by the veto of the Governor or by any means provided in the appropriations act or Title 39 of the Louisiana Revised Statutes of 1950 to prevent the total appropriation for the year from exceeding revenues for that year, or for any other lawful purpose, and the effect of such reduction is to provide insufficient monies for the continuation of the contract, the contract shall terminate on the date of the beginning of the first fiscal year for which funds are not appropriated.

14. Default of Contractor.

Failure to deliver within the time specified in the Bid will constitute a default and may cause cancellation of the contract. Where BRCC has determined the contractor to be in default, BRCC reserves the right to purchase any and all products or services covered by the contract on the open market and to charge the contractor with the cost in excess of the contract price. Until such assessed charges have been paid, no subsequent Bid from the defaulting contractor will be considered.

15. Order of Priority.

In the event there is a conflict between the Instructions to Bidder or Standard Terms and Conditions, the Standard Term and Conditions shall govern.

16. Applicable Law.

All contracts shall be construed in accordance with and governed by the laws of the State of Louisiana.

17. Terms and Conditions.

This solicitation contains all terms and conditions with respect to the commodities herein, any vendor contracts, forms, terms or other materials submitted with bid may cause bid to be rejected.

18. Increase/Decrease Clause.

The quantities listed herein are estimated to be the amount needed. In the event a greater or lesser quantity is needed, the right is reserved by BRCC to increase or decrease the amount, at the until price stated in the contract.

19. Late Payments.

Interest due by the Using Agency for late payments shall be in accordance with La. R.S. 39:1695 at the rates established in La. R.S. 13:4202.

20. Claims of Controversies.

Any claim or controversies arising out of this contract shall be resolved by the provisions of La. R.S. 39:1671-1673.

21. Equal Opportunity.

By submitting and signing the Bid, Bidder agrees that he will not discriminate in the rendering of services to and/or employment of individuals because of race, religion, sex, age, national origin, handicap or disability. Bidders shall keep informed of and comply with all Federal, State and local laws, ordinances and regulations which affect their employees or prospective employees.

22. Non-Exclusivity Clause.

This agreement is non-exclusive and shall not in any way preclude BRCC from entering into similar agreements and/or arrangements with other vendors, or from acquiring similar, equal or like goods and/or services from other entities or sources including state contracts.

23. Purpose.

The purpose of this contract is to provide the specified services. The terms and conditions of this specification are incorporated into and an essential part of the services. The contractor shall perform all services in a safe manner, in a manner to conform to the highest standard of good trade practices, in accordance with applicable laws and regulations and in accordance with manufacturer’s performance specifications.

24. Signature Authority.

ATTENTION: R.S. 39:1594(C)(4) REQUIRES EVIDENCE OF AUTHORITY TO SIGN AND SUBMIT BIDS TO THE STATE OF

LOUISIANA. YOU MUST INDICATE WHICH OF THE FOLLOWING APPLY TO THE SIGNER OF THIS BID.

PLEASE CIRCLE ONE.

1. THE SIGNER OF THIS BID IS EITHER A CORPORATE OFFICER WHO IS LISTED ON THE MOST CURRENT ANNUAL REPORT ON FILE WITH THE SECRETARY OF STATE OR A MEMBER OF A PARTNERSHIP OR PARTNERSHIP IN COMMENDAM AS REFLECTED IN THE MOST CURRENT PARTNERSHIP RECORDS ON FILE WITH THE SECRETARY OF STATE. A COPY OF THE ANNUAL REPORT OR PARTNERSHIP RECORD MUST BE SUBMITTED TO THIS OFFICE BEFORE CONTRACT AWARD.

2. THE SIGNER OF THE BID IS A REPRESENTATIVE OF THE BIDDER AUTHORIZED TO SUBMIT THIS BID AS EVIDENCED BY DOCUMENTS SUCH AS, CORPORATE RESOLUTION, CERTIFICATION AS TO CORPORATE PRINCIPAL, ETC. IF THIS APPLIES A COPY OF THE RESOLUTION, CERTIFICATION, OR OTHER SUPPORTIVE DOCUMENTS SHOULD BE ATTACHED HERETO.

3. THE BIDDER HAS FILED WITH THE SECRETARY OF STATE AN AFFIDAVIT OR RESOLUTION OR OTHER

ACKNOWLEDGED/ AUTHENTIC DOCUMENT INDICATING THAT THE SIGNER IS AUTHORIZED TO SUBMIT BIDS FOR PUBLIC CONTRACTS. A COPY OF THE APPLICABLE DOCUMENT SHOULD BE SUBMITTED TO THIS OFFICE BEFORE CONTRACT AWARD.

25. Bidder’s Responsibility.

It is the Bidder’s responsibility to check the LaPac website frequently for any possible addenda that may be issued. BRCC is not responsible for Bidder’s failure to download any Addenda documents required to complete the Invitation to Bid.

26. Bidder Inquiries.

An inquiry period is hereby firmly set for all interested bidders to perform a detailed review of the bid documents and to send any written inquiries relative thereto. Without exception, all inquiries MUST be given in writing by an authorized representative of the proposer, clearly cross-referenced to the relevant bid section. All inquiries must be received by 2:00 p.m. July 15, 2026. Only those inquiries received by the established deadline shall be considered by the State. Inquiries received after the established deadline shall not be entertained.

Inquiries concerning this bid can be emailed to:

Name: Desiree Brown E-mail: brownd3@mybrcc.edu An addendum will be issued and posted to the LAPAC website to address all workable inquiries received and any other changes or clarifications to the bid. No negotiations, decisions or actions shall be executed by any bidder because of any oral discussions with any BRCC employee or consultant. It is the bidder’s responsibility to check the LAPAC website regularly for addenda that may be issued.

BID FORM

Please quote intercollegiate sports accident insurance for August 15, 2026, through August 14, 2027 (with two (2) optional annual renewals).

National Junior College Athletic Association (NJCAA) Roster Estimates by Sport

Men’s Basketball – 18

Women’s Basketball – 18

Men’s Baseball – 45

Women’s Softball – 21 I. Quote for Annual Accident Insurance Policy

$500 deductible per injury Alternate deductibles

· $1,000 deductible per injury

· $2,500 deductible per injury

Core benefit $25,000 w/full dental and full physical therapy included.

1. Reasonable and customary covered medical expenses paid at 100% after the deductible.

2. Three (3) year benefit period.

3. No aggregate limit for medical expenses.

4. Coverage for ‘repetitive motion injuries’ resulting from the play, practice or conditioning of intercollegiate sports. Injuries such as strains, sprains, hernia, tennis elbow, tendonitis, bursitis and muscle tears not covered unless resulting from a specific injury.

5. Coverage for injuries resulting from a heart of circulatory malfunction.

6. Coverage to include the re-injuring and /or aggravation of an injury which occurred prior to the effective date of the insured person’s coverage under the policy or which occurred during the policy term and such injury was not fully resolved at the time of the re-injury.

7. Reducing deductible met by benefits paid by other plans.

8. Coverage for expenses denied or reduced by an HMO or PPO because of noncompliance with their rules.

9. Initial expense must be incurred within 180 days of the injury.

10. Access to HMO and PPO networks.

$10,000 AD&D benefit / $500,000 aggregate.

Claim History embedded below for reference.

Current Premium for August 15, 2025 - August 14, 2026: Accident $ 67,772 Catastrophic $ 6,160

ANNUAL ACCIDENT PREMIUM

ALTERNATE 1: EXCLUDING REPETITIVE MOTION INJURY COVERAGE

ANNUAL ACCIDENT PREMIUM excluding repetitive motion injury coverage

ALTERNATE 2: WITH CORE MEDICAL MAXIMUM BENEFIT

ANNUAL ACCIDENT PREMIUM with $15,0000 benefit maximum

ANNUAL ACCIDENT PREMIUM with $20,000 benefit maximum

ALTERNATE 3: WITH CAPPED PHYSICAL THERAPY BENEFITS

ANNUAL ACCIDENT PREMIUM with capped physical therapy benefits

II. Quote for a Catastrophic Insurance Policy.

$25,000 deductible

$5,000,000 maximum amount payable for all expenses resulting from the same injury

DO NOT link a premium price for Lifetime Catastrophic Coverage to an Accident Policy.

ANNUAL CATASTROPHIC PREMIUM

Are these prices linked to an Accident Policy? Yes ____ No ____

ANNUAL LIFETIME CATASTROPHIC PREMIUM

Are these prices linked to an Accident Policy? Yes ____ No _____

Optional:

Loss Ratios by Year (if available) Women’s Basketball _________

Men’s Basketball _________

Baseball ________

Softball __________

_1845022705.pdf

Baton Rouge Community College, Policy Begin Year: 2021, Policy End Year: 2025

A-G Administrators, Inc.

Report Criteria:

6/29/2026 4:34:24 PM

Pay Dates: 01/01/1900 - 06/29/2026 Claims History Report

Service

Date

Payee Name Coverage Amount Claimed Reduction

Amount

Reduction Reason Amount Paid Date

Received

Check Date Check

Number

Baton Rouge Community CollegeClient:

2021Underwriting Year:

174-127-001-PPolicy:

Coverage: Not Specified

Checking Account:

B., Jacob; Claim: 275737; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Unspecified; Date Incurred: 08/18/2021

08/27/2021 Ded Credit 09/27/2021 0 $167.00 $0.00 09/27/2021$167.00

09/29/2021 Ded Credit 10/06/2021 0 $154.00 $0.00 10/06/2021$154.00

Claim # 275737 Totals : $321.00 $0.00$321.00

B., Jacob; Claim: 278679; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/11/2022

01/12/2022 Ded Credit 01/19/2022 0 $355.00 $0.00 01/19/2022$355.00

01/12/2022 Ded Credit 01/19/2022 0 $50.00 $0.00 01/19/2022$50.00

Claim # 278679 Totals : $405.00 $0.00$405.00

B., Jacob; Claim: 281496; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/23/2022

04/13/2022 Ded Credit 08/01/2022 0 $355.00 $0.00 08/01/2022$355.00

Claim # 281496 Totals : $355.00 $0.00$355.00

C., Jameison; Claim: 279274; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 01/14/2022

02/01/2022 Ded Credit 02/24/2022 0 $23.00 $0.00 02/24/2022$23.00

02/01/2022 Ded Credit 03/31/2022 0 $358.00 $0.00 03/31/2022$358.00

03/31/2022 Max Benefit 10/11/2022 0 $2,875.00 $0.00 10/11/2022$2,875.00

03/31/2022 Max Benefit 10/11/2022 0 $1,500.88 $0.00 10/11/2022$1,500.88

03/31/2022 Max Benefit 10/11/2022 0 $545.62 $0.00 10/11/2022$545.62

10/26/2022 Max Benefit 11/14/2022 0 $664.00 $0.00 11/14/2022$664.00

Claim # 279274 Totals : $5,966.50 $0.00$5,966.50

D., Alana; Claim: 275510; Activity: Women's Basketball; Diagnosis: Pain; Anatomy: Unspecified; Date Incurred: 08/24/2021

09/20/2021 Ded Credit 10/04/2021 0 $331.00 $0.00 10/04/2021$331.00

09/20/2021 Ded Credit 11/02/2021 0 $40.00 $0.00 11/02/2021$40.00

02/14/2022 Not-payable 03/31/2022 0 $223.00 $0.00 03/31/2022$223.00

02/14/2022 Not-payable 03/31/2022 0 $256.00 $0.00 03/31/2022$256.00

02/14/2022 Not-payable 01/17/2023 0 $223.00 $0.00 01/17/2023$223.00

Claim # 275510 Totals : $1,073.00 $0.00$1,073.00

E., Kelsie; Claim: 279278; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Back; Date Incurred: 02/07/2022

02/14/2022 Other Ins Paid 03/09/2022 0 $256.00 03/09/2022$33.42

03/09/2022 0 03/09/2022Primary Adjustm$162.58

03/09/2022 0 $0.00 03/09/2022Ded Credit$60.00

02/08/2022 Primary Adjustm 03/10/2022 0 $380.00 03/10/2022$251.34

03/10/2022 0 $0.00 03/10/2022Ded Credit$128.66

Claim # 279278 Totals : $636.00 $0.00$636.00

H., Elliot; Claim: 279277; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Ankle; Date Incurred: 01/30/2022

01/31/2022 Primary Adjustm 03/04/2022 0 $167.00 03/04/2022$108.79

03/04/2022 0 $0.00 03/04/2022Ded Credit$58.21

01/31/2022 Primary Adjustm 04/04/2022 0 $511.00 04/04/2022$293.53

04/04/2022 0 $0.00 04/04/2022Ded Credit$217.47

01/31/2022 Primary Adjustm 04/04/2022 0 $20.00 04/04/2022$3.55

04/04/2022 0 $0.00 04/04/2022Ded Credit$16.45

02/01/2022 Primary Adjustm 06/17/2022 0 $154.00 06/17/2022$24.74

06/17/2022 0 $0.00 06/17/2022Ded Credit$129.26

03/25/2022 Not-payable 06/17/2022 0 $60.00 $0.00 06/17/2022$60.00

03/25/2022 Primary Adjustm 06/17/2022 0 $358.00 06/17/2022$216.72

06/17/2022 0 $0.00 06/17/2022Not-payable$141.28

Claim # 279277 Totals : $1,270.00 $0.00$1,270.00

L., Rebecka; Claim: 275383; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 09/07/2021

09/14/2021 Ded Credit 11/01/2021 0 $3.88 11/01/2021$3.88

11/01/2021 0 $0.00 11/01/2021Ded Credit$-3.88

09/14/2021 Ded Credit 11/01/2021 0 $13.08 11/01/2021$13.08

11/01/2021 0 $0.00 11/01/2021Ded Credit$-13.08

09/24/2021 Ded Credit 12/02/2021 0 $50.00 12/02/2021$50.00

12/02/2021 0 $0.00 12/02/2021Ded Credit$-50.00

09/14/2021 Ded Credit 01/03/2022 0 $50.00 01/03/2022$50.00

01/03/2022 0 $0.00 01/03/2022Ded Credit$-50.00

Claim # 275383 Totals : $116.96 $0.00$116.96

M., Ethan; Claim: 277641; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 09/27/2021

12/02/2021 Not Covered 12/27/2021 0 $356.38 12/27/2021$356.38

12/27/2021 0 $0.00 12/27/2021Adjustment$356.38

Claim # 277641 Totals : $356.38 $0.00$356.38

S., Hayden; Claim: 275957; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Elbow; Date Incurred: 09/30/2021

10/11/2021 Adjustment 11/18/2021 0 -$30.55 11/18/2021$-30.55

11/18/2021 0 11/18/2021Adjustment$61.10

11/18/2021 0 $0.00 11/18/2021Ded Credit$-30.55

10/11/2021 Ded Credit 11/18/2021 0 $30.55 11/18/2021$30.55

11/18/2021 0 $0.00 11/18/2021Adjustment$-30.55

10/06/2021 Ded Credit 11/18/2021 0 $51.78 11/18/2021$51.78

11/18/2021 0 $0.00 11/18/2021Ded Credit$-51.78

11/16/2021 Other Ins Paid 12/20/2021 0 $80.00 12/20/2021$4.29

12/20/2021 0 12/20/2021Primary Adjustm$35.71

12/20/2021 0 $0.00 12/20/2021Ded Credit$40.00

Claim # 275957 Totals : $131.78 $0.00$131.78

S., Montana; Claim: 280301; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Back; Date Incurred: 03/08/2022

05/06/2022 Ded Credit 05/31/2022 0 $45.00 05/31/2022$45.00

05/31/2022 0 $0.00 05/31/2022Ded Credit$-45.00

05/04/2022 Ded Credit 05/31/2022 0 $45.00 05/31/2022$45.00

05/31/2022 0 $0.00 05/31/2022Ded Credit$-45.00

Claim # 280301 Totals : $90.00 $0.00$90.00

$10,721.62 $10,721.62 $0.002021 Sub Total: Checking Account Totals:

Checking Account: FA-Guarantee Trust Life Insurance Compan

B., Jacob; Claim: 275737; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Unspecified; Date Incurred: 08/18/2021

08/27/2021 Ded Credit 05/03/2022 2330060574 Ochsner Medical Center $358.00 $179.00 04/21/2022$179.00

08/27/2021 05/03/2022 2330060575 Ochsner Clinic LLC $20.00 $20.00 04/21/2022$0.00

10/11/2021 Disc:OccuNet 06/02/2022 2330062173 Ochsner Medical Center $2,855.00 11/10/2021$651.25

06/02/2022 2330062173 $250.00 11/10/2021Disc:OccuNet$1,953.75

10/11/2021 06/02/2022 2330062174 OccuNet $651.25 $651.25 11/10/2021$0.00

09/29/2021 Disc:OccuNet 06/02/2022 2330062170 Ochsner Medical Center $1,408.00 10/12/2021$300.57

06/02/2022 2330062170 $205.73 10/12/2021Disc:OccuNet$901.70

09/29/2021 06/02/2022 2330062175 OccuNet $300.57 $300.57 10/12/2021$0.00

11/10/2021 Disc:OccuNet 06/02/2022 2330062171 Ochsner Medical Center $1,587.00 12/13/2021$359.25

06/02/2022 2330062171 $150.00 12/13/2021Disc:OccuNet$1,077.75

11/10/2021 06/02/2022 2330062172 OccuNet $359.25 $359.25 12/13/2021$0.00

Claim # 275737 Totals : $7,539.07 $2,115.80$5,423.27

B., Jacob; Claim: 278679; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/11/2022

01/12/2022 02/28/2022 2330057017 OccuNet $397.67 $397.67 01/25/2022$0.00

01/12/2022 Disc:OccuNet 02/28/2022 2330057016 Ochsner Medical Center $1,800.00 01/25/2022$397.67

02/28/2022 2330057016 $209.31 01/25/2022Disc:OccuNet$1,193.02

01/12/2022 03/03/2022 2330057248 Ochsner Clinic LLC $154.00 $154.00 02/15/2022$0.00

01/13/2022 Ded Credit 03/03/2022 2330057247 Ochsner Clinic LLC $256.00 $161.00 02/16/2022$95.00

Claim # 278679 Totals : $2,607.67 $921.98$1,685.69

B., Jacob; Claim: 281496; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/23/2022

04/07/2022 Ded Credit 08/29/2022 2330066396 Ochsner Clinic LLC $256.00 $111.00 05/10/2022$145.00

04/08/2022 08/29/2022 2330066398 Ochsner Clinic LLC $154.00 $154.00 07/21/2022$0.00

04/07/2022 08/29/2022 2330066397 Ochsner Clinic LLC $50.00 $50.00 05/10/2022$0.00

Claim # 281496 Totals : $460.00 $315.00$145.00

C., Jameison; Claim: 279274; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 01/14/2022

02/01/2022 Ded Credit 04/26/2022 2330060114 Ochsner Clinic LLC $307.00 $188.00 04/13/2022$119.00

03/31/2022 Max Benefit 04/26/2022 2330060115 Ochsner Medical Center $41,275.07 $24,812.00 04/18/2022$16,463.07

Claim # 279274 Totals : $41,582.07 $25,000.00$16,582.07

D., Alana; Claim: 275510; Activity: Women's Basketball; Diagnosis: Pain; Anatomy: Unspecified; Date Incurred: 08/24/2021

09/20/2021 Over UCR 11/10/2021 2330052286 Ochsner Clinic LLC $358.00 11/02/2021$128.79

11/10/2021 2330052286 $100.21 11/02/2021Ded Credit$129.00

10/01/2021 Disc:OccuNet 05/12/2022 2330061083 Ochsner Clinic LLC $511.00 03/31/2022$86.93

05/12/2022 2330061083 $163.28 03/31/2022Disc:OccuNet$260.79

10/01/2021 05/12/2022 2330061084 OccuNet $86.93 $86.93 03/31/2022$0.00

05/26/2022 Disc:OccuNet 08/10/2022 2330065499 Ochsner Clinic LLC $355.00 06/06/2022$50.17

08/10/2022 2330065499 $154.34 06/06/2022Disc:OccuNet$150.49

05/26/2022 08/10/2022 2330065498 OccuNet $50.17 $50.17 06/06/2022$0.00

Claim # 275510 Totals : $1,361.10 $554.93$806.17

E., Kelsie; Claim: 279278; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Back; Date Incurred: 02/07/2022

03/23/2022 Primary Adjustm 05/03/2022 2330060576 Radiology Specialists $1,150.00 04/21/2022$785.91

05/03/2022 2330060576 04/21/2022Ded Credit$311.34

05/03/2022 2330060576 $86.17 04/21/2022Ded Credit$-33.42

02/08/2022 Primary Adjustm 06/01/2022 2330062107 Ochsner Clinic LLC $40.00 $31.82 05/19/2022$8.18

02/08/2022 Primary Adjustm 06/01/2022 2330062108 Ochsner Clinic LLC $355.00 05/24/2022$217.10

06/01/2022 2330062108 $60.00 05/24/2022Other Ins Paid$77.90

03/07/2022 Other Ins Paid 07/05/2022 2330063729 Geaux Chiro $2,725.00 06/21/2022$713.53

07/05/2022 2330063729 06/21/2022Primary Adjustm$1,261.71

07/05/2022 2330063729 $560.00 06/21/2022Primary Adjustm$189.76

Claim # 279278 Totals : $4,270.00 $737.99$3,532.01

G., Braxton; Claim: 280671; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Hamstring; Date Incurred: 01/14/2022

04/01/2022 Primary Adjustm 01/12/2023 2330072308 Ochsner Medical Center $1,102.00 12/28/2022$208.00

01/12/2023 2330072308 $394.00 12/28/2022Ded Credit$500.00

Claim # 280671 Totals : $1,102.00 $394.00$708.00

G., Alex; Claim: 276327; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Hamstring; Date Incurred: 10/10/2021

11/02/2021 Primary Adjustm 02/23/2022 2330056761 Ochsner Medical Center $3,234.00 02/07/2022$1,470.31

02/23/2022 2330056761 $352.74 02/07/2022Other Ins Paid$1,410.95

10/18/2021 Other Ins Paid 09/01/2022 2330066624 Ochsner Clinic LLC $355.00 01/04/2022$115.66

09/01/2022 2330066624 $25.00 01/04/2022Primary Adjustm$214.34

10/14/2021 Primary Adjustm 12/13/2022 2330070846 Ochsner Medical Center $1,410.00 02/07/2022$421.32

12/13/2022 2330070846 $527.74 02/07/2022Other Ins Paid$460.94

Claim # 276327 Totals : $4,999.00 $905.48$4,093.52

H., Elliot; Claim: 279277; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Ankle; Date Incurred: 01/30/2022

02/23/2022 Primary Adjustm 09/22/2022 2330067388 Ochsner Medical Center $1,539.00 06/07/2022$699.57

09/22/2022 2330067388 06/07/2022Ded Credit$78.61

09/22/2022 2330067388 $150.00 06/07/2022Misc. Conversion$610.82

02/23/2022 09/22/2022 2330067391 OccuNet $172.36 $172.36 06/07/2022$0.00

02/01/2022 Primary Adjustm 09/22/2022 2330067389 Ochsner Medical Center $1,408.00 06/07/2022$420.35

09/22/2022 2330067389 06/07/2022Disc:OccuNet$194.59

09/22/2022 2330067389 $209.31 06/07/2022Disc:OccuNet$583.75

02/01/2022 09/22/2022 2330067390 OccuNet $194.59 $194.59 06/07/2022$0.00

Claim # 279277 Totals : $3,313.95 $726.26$2,587.69

L., Rebecka; Claim: 275383; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 09/07/2021

10/08/2021 Other Ins Paid 03/08/2022 2330057478 BROC Therapy Services $775.00 02/23/2022$46.16

03/08/2022 2330057478 $244.63 02/23/2022Primary Adjustm$484.21

10/01/2021 Other Ins Paid 03/08/2022 2330057477 BROC Therapy Services $325.00 02/22/2022$99.98

03/08/2022 2330057477 $50.00 02/22/2022Primary Adjustm$175.02

09/16/2021 Other Ins Paid 03/08/2022 2330057480 Ochsner Clinic LLC $182.00 02/22/2022$136.09

03/08/2022 2330057480 $34.02 02/22/2022Primary Adjustm$11.89

09/16/2021 Primary Adjustm 03/08/2022 2330057479 Ochsner Clinic LLC $413.00 02/22/2022$236.57

03/08/2022 2330057479 $35.29 02/22/2022Other Ins Paid$141.14

09/24/2021 Primary Adjustm 03/24/2022 2330058425 Ochsner Clinic LLC $256.00 12/02/2021$140.12

03/24/2022 2330058425 $50.00 12/02/2021Other Ins Paid$65.88

09/14/2021 Other Ins Paid 03/24/2022 2330058427 Ochsner Clinic LLC $23.00 11/01/2021$15.52

03/24/2022 2330058427 $3.88 11/01/2021Primary Adjustm$3.60

09/14/2021 Primary Adjustm 03/24/2022 2330058424 Ochsner Clinic LLC $358.00 01/03/2022$191.14

03/24/2022 2330058424 $50.00 01/03/2022Other Ins Paid$116.86

09/16/2021 Other Ins Paid 03/24/2022 2330058428 Ochsner Medical Center $2,581.98 03/14/2022$661.60

03/24/2022 2330058428 $490.40 03/14/2022Primary Adjustm$1,429.98

09/14/2021 Primary Adjustm 03/24/2022 2330058426 Ochsner Medical Center $174.00 11/01/2021$108.58

03/24/2022 2330058426 $13.08 11/01/2021Other Ins Paid$52.34

Claim # 275383 Totals : $5,087.98 $971.30$4,116.68

M., Ethan; Claim: 277641; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 09/27/2021

12/08/2021 Other Ins Paid 01/04/2022 2330054215 Moreau Physical Therapy $335.00 12/27/2021$136.29

01/04/2022 2330054215 $34.08 12/27/2021Primary Adjustm$164.63

12/09/2021 Other Ins Paid 01/04/2022 2330054214 Moreau Physical Therapy $218.00 12/27/2021$99.63

01/04/2022 2330054214 $24.91 12/27/2021Primary Adjustm$93.46

12/13/2021 Primary Adjustm 01/18/2022 2330054824 Moreau Physical Therapy $872.00 01/03/2022$373.84

01/18/2022 2330054824 $99.64 01/03/2022Other Ins Paid$398.52

11/24/2021 Other Ins Paid 01/19/2022 2330054933 Opelousas General Health $530.00 01/11/2022$113.88

01/19/2022 2330054933 $68.02 01/11/2022Primary Adjustm$348.10

12/29/2021 Other Ins Paid 02/02/2022 2330055612 Moreau Physical Therapy $218.00 01/18/2022$27.59

02/02/2022 2330055612 $96.95 01/18/2022Primary Adjustm$93.46

11/19/2021 Primary Adjustm 02/25/2022 2330056943 Ochsner Clinic LLC $23.00 $19.28 02/11/2022$3.72

11/19/2021 Primary Adjustm 02/25/2022 2330056942 Ochsner Clinic LLC $358.00 $141.28 02/10/2022$216.72

12/02/2021 Other Ins Paid 02/28/2022 2330057019 Opelousas General Health $1,632.00 02/11/2022$677.00

02/28/2022 2330057019 $162.54 02/11/2022Primary Adjustm$792.46

11/19/2021 Primary Adjustm 02/28/2022 2330057018 Ochsner Medical Center $1,800.00 02/10/2022$675.70

02/28/2022 2330057018 $224.86 02/10/2022Other Ins Paid$899.44

11/19/2021 Primary Adjustm 02/28/2022 2330057020 Ochsner Clinic LLC $27.00 $22.54 02/11/2022$4.46

12/02/2021 Other Ins Paid 03/18/2022 2330058083 Doctors Anesthesia $416.00 03/03/2022$329.89

03/18/2022 2330058083 $82.47 03/03/2022Primary Adjustm$3.64

12/02/2021 Other Ins Paid 06/24/2022 2330063265 ASC of Opelousas $1,916.90 $356.38 12/27/2021$1,560.52

12/27/2021 Other Ins Paid 08/08/2022 2330065400 Moreau Physical Therapy $218.00 07/22/2022$99.63

08/08/2022 2330065400 $24.91 07/22/2022Primary Adjustm$93.46

11/19/2021 Primary Adjustm 09/01/2022 2330066625 Ochsner Clinic LLC $154.00 02/11/2022$154.00

09/01/2022 2330066625 $129.26 02/11/2022Primary Adjustm$-129.26

Claim # 277641 Totals : $8,717.90 $1,487.12$7,230.78

P., Sarah; Claim: 280290; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 03/07/2022

04/01/2022 Other Ins Paid 05/17/2022 2330061303 BRRG $635.00 05/06/2022$103.36

05/17/2022 2330061303 $25.84 05/06/2022Primary Adjustm$505.80

04/01/2022 Primary Adjustm 05/17/2022 2330061304 BRRG $250.00 05/06/2022$126.36

05/17/2022 2330061304 $24.73 05/06/2022Other Ins Paid$98.91

04/01/2022 Primary Adjustm 07/21/2022 2330064465 Baton Rouge General Medical Center $4,037.45 04/29/2022$1,581.34

07/21/2022 2330064465 $1,925.53 04/29/2022Other Ins Paid$530.58

07/19/2022 Adjustment 07/21/2022 2330064464 Baton Rouge General Medical Center $0.00 $0.00 07/19/2022$24.06

03/18/2022 Primary Adjustm 04/11/2023 2330078223 Ochsner Clinic LLC $23.00 03/31/2022$3.72

04/11/2023 2330078223 $3.86 03/31/2022Other Ins Paid$15.42

03/18/2022 Other Ins Paid 04/11/2023 2330078222 Ochsner Clinic LLC $358.00 03/31/2022$113.02

04/11/2023 2330078222 $28.26 03/31/2022Primary Adjustm$216.72

Claim # 280290 Totals : $5,303.45 $2,008.22$3,295.23

S., Hayden; Claim: 275957; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Elbow; Date Incurred: 09/30/2021

11/02/2021 Other Ins Paid 02/03/2022 2330055703 BROC Therapy Services $620.00 01/25/2022$144.88

02/03/2022 2330055703 $62.06 01/25/2022Primary Adjustm$413.06

11/17/2021 Other Ins Paid 02/03/2022 2330055704 BROC Therapy Services $310.00 01/25/2022$72.44

02/03/2022 2330055704 $31.03 01/25/2022Primary Adjustm$206.53

10/14/2021 Other Ins Paid 03/15/2022 2330057892 BROC Therapy Services $1,550.00 02/25/2022$356.65

03/15/2022 2330057892 $152.75 02/25/2022Primary Adjustm$1,040.60

10/06/2021 Other Ins Paid 03/15/2022 2330057893 BROC Therapy Services $510.00 11/18/2021$120.88

03/15/2022 2330057893 $51.78 11/18/2021Primary Adjustm$337.34

10/11/2021 Other Ins Paid 03/15/2022 2330057894 BROC Therapy Services $310.00 11/18/2021$71.33

03/15/2022 2330057894 $30.55 11/18/2021Primary Adjustm$208.12

11/05/2021 Other Ins Paid 03/15/2022 2330057895 BROC Therapy Services $310.00 12/20/2021$72.44

03/15/2022 2330057895 $31.03 12/20/2021Primary Adjustm$206.53

Claim # 275957 Totals : $3,610.00 $359.20$3,250.80

S., Montana; Claim: 280301; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Back; Date Incurred: 03/08/2022

04/06/2022 Primary Adjustm 06/28/2022 2330063397 Ochsner Medical Center $1,415.00 06/16/2022$456.17

06/28/2022 2330063397 $541.30 06/16/2022Other Ins Paid$417.53

05/27/2022 Other Ins Paid 07/15/2022 2330064208 LMG LLC $320.00 06/27/2022$106.75

07/15/2022 2330064208 $30.00 06/27/2022Primary Adjustm$183.25

04/06/2022 Primary Adjustm 08/09/2022 2330065459 Ochsner Clinic LLC $168.00 $137.64 07/29/2022$30.36

05/06/2022 Other Ins Paid 08/09/2022 2330065458 LMG LLC $320.00 05/31/2022$54.32

08/09/2022 2330065458 $45.00 05/31/2022Primary Adjustm$220.68

05/04/2022 Other Ins Paid 08/09/2022 2330065460 LMG LLC $215.00 05/31/2022$23.74

08/09/2022 2330065460 $45.00 05/31/2022Primary Adjustm$146.26

06/24/2022 Other Ins Paid 09/01/2022 2330066626 LMG LLC $215.00 08/11/2022$21.79

09/01/2022 2330066626 $45.00 08/11/2022Primary Adjustm$148.21

Claim # 280301 Totals : $2,653.00 $843.94$1,809.06

$92,607.19 $55,265.97 $37,341.222021 Sub Total: Checking Account FA-Guarantee Trust Life Ins

$103,328.81 $37,341.22$65,987.592021 Sub Total: Coverage Not Specified Totals:

$103,328.81 $65,987.59 $37,341.222021 Sub Total: Policy 174-127-001-P Totals:

$103,328.81 $65,987.59 $37,341.222021 Sub Totals:

2022Underwriting Year:

174-127-001-QPolicy:

J., Britt; Claim: 288193; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 02/01/2023

03/16/2023 Other Ins Paid 08/29/2023 0 $120.00 08/29/2023$23.78

08/29/2023 0 08/29/2023Ded Credit$55.00

08/29/2023 0 $0.00 08/29/2023Primary Adjustm$41.22

02/14/2023 Other Ins Paid 08/29/2023 0 $464.00 08/29/2023$173.34

08/29/2023 0 08/29/2023Ded Credit$55.00

08/29/2023 0 $0.00 08/29/2023Primary Adjustm$235.66

Claim # 288193 Totals : $584.00 $0.00$584.00

W., Antonio; Claim: 288156; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/12/2023

01/23/2023 Not-payable 02/24/2023 0 $45.08 02/24/2023$45.08

02/24/2023 0 $0.00 02/24/2023Adjustment$45.08

Claim # 288156 Totals : $45.08 $0.00$45.08

Z., Slade; Claim: 291769; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 03/08/2023

04/10/2023 Adjustment 08/30/2023 0 $201.00 $0.00 08/30/2023$201.00

Claim # 291769 Totals : $201.00 $0.00$201.00

$830.08 $830.08 $0.002022 Sub Total: Checking Account Totals:

A., Morgan; Claim: 290891; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 03/03/2023

03/16/2023 Other Ins Paid 06/30/2023 2330084120 BROC Therapy Services $4,625.00 05/30/2023$599.72

06/30/2023 2330084120 $704.70 05/30/2023Primary Adjustm$3,320.58

Claim # 290891 Totals : $4,625.00 $704.70$3,920.30

F., Lane; Claim: 289723; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Arm; Date Incurred: 02/13/2023

03/09/2023 Other Ins Paid 05/26/2023 2330081496 BROC Therapy Services $1,875.00 05/05/2023$552.24

05/26/2023 2330081496 $200.00 05/05/2023Primary Adjustm$1,122.76

04/06/2023 Other Ins Paid 05/26/2023 2330081495 Baton Rouge Orthopaedic Clinic $120.00 04/24/2023$34.35

05/26/2023 2330081495 $40.00 04/24/2023Primary Adjustm$45.65

03/07/2023 Other Ins Paid 05/26/2023 2330081497 Baton Rouge Orthopaedic Clinic $120.00 03/31/2023$34.35

05/26/2023 2330081497 $40.00 03/31/2023Primary Adjustm$45.65

02/20/2023 Other Ins Paid 05/26/2023 2330081498 Baton Rouge Orthopaedic Clinic $270.00 03/31/2023$111.89

05/26/2023 2330081498 $40.00 03/31/2023Primary Adjustm$118.11

03/27/2023 Other Ins Paid 06/27/2023 2330083748 BROC Therapy Services $850.00 05/30/2023$199.80

06/27/2023 2330083748 $80.00 05/30/2023Primary Adjustm$570.20

03/01/2023 Other Ins Paid 06/27/2023 2330083749 Radiology Specialists $668.00 06/05/2023$143.17

06/27/2023 2330083749 $46.88 06/05/2023Primary Adjustm$477.95

Claim # 289723 Totals : $3,903.00 $446.88$3,456.12

I., Jennifer; Claim: 288194; Activity: Women's Softball; Diagnosis: Pain; Anatomy: Unspecified; Date Incurred: 02/09/2023

04/17/2023 Primary Adjustm 06/21/2023 2330083376 Anesthesiology Group Associate $375.00 $273.78 05/25/2023$101.22

04/17/2023 Other Ins Paid 06/21/2023 2330083377 Lake Surgery Center $9,093.00 06/02/2023$2,048.81

06/21/2023 2330083377 $665.62 06/02/2023Primary Adjustm$6,378.57

Claim # 288194 Totals : $9,468.00 $939.40$8,528.60

J., Britt; Claim: 288193; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 02/01/2023

02/14/2024 Other Ins Paid 04/25/2024 2330103158 Baton Rouge Orthopaedic Clinic $464.00 03/25/2024$173.34

04/25/2024 2330103158 03/25/2024Primary Adjustm$235.66

04/25/2024 2330103158 $35.46 03/25/2024Ded Credit$19.54

Claim # 288193 Totals : $464.00 $35.46$428.54

W., Antonio; Claim: 288156; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: Knee; Date Incurred: 01/12/2023

01/12/2023 Primary Adjustm 03/24/2023 2330077067 Ochsner Medical Center $432.00 $76.72 02/27/2023$355.28

01/31/2023 Other Ins Paid 05/02/2023 2330079636 Ochsner Hospital for Orth $61,641.28 03/03/2023$11,892.02

05/02/2023 2330079636 $6,692.75 03/03/2023Primary Adjustm$43,056.51

01/31/2023 Adjustment 05/02/2023 2330079637 Ochsner Hospital for Orth $0.00 $0.00 04/28/2023$30.80

01/19/2023 Other Ins Paid 05/25/2023 2330081321 Baton Rouge Orthopaedic Clinic $120.00 03/10/2023$18.78

05/25/2023 2330081321 $60.00 03/10/2023Primary Adjustm$41.22

01/13/2023 Other Ins Paid 05/25/2023 2330081320 Baton Rouge Orthopaedic Clinic $410.00 03/10/2023$154.18

05/25/2023 2330081320 $60.00 03/10/2023Primary Adjustm$195.82

01/23/2023 Primary Adjustm 08/25/2023 2330087759 Ochsner Clinic LLC $54.00 $45.08 02/24/2023$8.92

Claim # 288156 Totals : $62,657.28 $6,934.55$55,722.73

Z., Slade; Claim: 291769; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: Shoulder; Date Incurred: 03/08/2023

09/15/2023 0 $0.00 -$25.00 09/15/2023$0.00

03/30/2023 Other Ins Paid 09/28/2023 2330089579 BROC Therapy Services $1,955.00 09/15/2023$440.96

09/28/2023 2330089579 $100.00 09/15/2023Primary Adjustm$1,414.04

04/17/2023 Other Ins Paid 09/28/2023 2330089577 BROC Therapy Services $2,115.00 09/15/2023$513.91

09/28/2023 2330089577 $125.00 09/15/2023Primary Adjustm$1,476.09

04/13/2023 Primary Adjustm 09/28/2023 2330089578 Baton Rouge Orthopaedic Clinic $120.00 08/30/2023$41.22

09/28/2023 2330089578 $25.00 08/30/2023Other Ins Paid$53.78

04/13/2023 Other Ins Paid 10/27/2023 2330091175 Baton Rouge General Medical Center $120.00 09/15/2023$53.78

10/27/2023 2330091175 $25.00 09/15/2023Primary Adjustm$41.22

03/21/2023 Other Ins Paid 10/27/2023 2330091174 Baton Rouge Orthopaedic Clinic $464.00 08/30/2023$97.22

10/27/2023 2330091174 $131.15 08/30/2023Primary Adjustm$235.63

04/13/2023 11/10/2023 2330091822 Baton Rouge Orthopaedic Clinic $25.00 $25.00 09/15/2023$0.00

03/23/2023 Other Ins Paid 12/22/2023 2330094218 Slade Zeppuhar $560.00 08/30/2023$164.03

12/22/2023 2330094218 $25.00 08/30/2023Primary Adjustm$370.97

01/23/2024 Other Ins Paid 03/14/2024 2330099879 BROC Therapy Services $220.00 02/20/2024$99.84

03/14/2024 2330099879 $25.00 02/20/2024Primary Adjustm$95.16

03/14/2024 Other Ins Paid 05/06/2024 2330103862 BROC Therapy Services $270.00 04/08/2024$120.58

05/06/2024 2330103862 $25.00 04/08/2024Primary Adjustm$124.42

02/21/2024 Primary Adjustm 05/06/2024 2330103863 BROC Therapy Services $2,200.00 $418.08 04/01/2024$1,781.92

06/04/2024 Other Ins Paid 07/29/2024 2330110673 Baton Rouge Orthopaedic Clinic $270.00 07/01/2024$120.58

07/29/2024 2330110673 $25.00 07/01/2024Primary Adjustm$124.42

07/10/2024 Other Ins Paid 08/22/2024 2330112816 Baton Rouge Orthopaedic Clinic $5,450.00 08/01/2024$1,337.88

08/22/2024 2330112816 $334.47 08/01/2024Primary Adjustm$3,777.65

07/10/2024 Other Ins Paid 08/22/2024 2330112815 Baton Rouge Orthopaedic Clinic $1,090.00 08/01/2024$227.44

08/22/2024 2330112815 $56.86 08/01/2024Primary Adjustm$805.70

07/10/2024 Other Ins Paid 02/13/2025 2330124293 Louisana Ortho Surgery $22,056.00 12/24/2024$3,670.14

02/13/2025 2330124293 $917.53 12/24/2024Primary Adjustm$17,468.33

Claim # 291769 Totals : $36,915.00 $2,233.09$34,681.91

$118,032.28 $106,738.20 $11,294.082022 Sub Total: Checking Account FA-Guarantee Trust Life Ins

$118,862.36 $11,294.08$107,568.282022 Sub Total: Coverage Not Specified Totals:

$118,862.36 $107,568.28 $11,294.082022 Sub Total: Policy 174-127-001-Q Totals:

$118,862.36 $107,568.28 $11,294.082022 Sub Totals:

2023Underwriting Year:

174-127-001-RPolicy:

Coverage: (FA) BLANKET SPORTS

B., Cole; Claim: 298642; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: L-Ankle; Date Incurred: 02/09/2024

03/06/2024 Ded Credit 10/21/2024 0 $13.08 10/21/2024$13.08

10/21/2024 0 $0.00 10/21/2024Ded Credit$-13.08

03/08/2024 Ded Credit 10/21/2024 0 $48.42 10/21/2024$48.42

10/21/2024 0 $0.00 10/21/2024Ded Credit$-48.42

03/11/2024 Ded Credit 10/21/2024 0 $13.08 10/21/2024$13.08

10/21/2024 0 $0.00 10/21/2024Ded Credit$-13.08

03/18/2024 Other Ins Paid 04/04/2025 0 $760.00 04/04/2025$50.00

04/04/2025 0 $0.00 04/04/2025Primary Adjustm$424.00

04/03/2024 Other Ins Paid 04/04/2025 0 $4,079.00 04/04/2025$300.00

04/04/2025 0 $0.00 04/04/2025Primary Adjustm$2,063.00

05/03/2024 Other Ins Paid 04/04/2025 0 $2,042.00 04/04/2025$150.00

04/04/2025 0 $0.00 04/04/2025Primary Adjustm$962.00

03/06/2024 Other Ins Paid 04/04/2025 0 $62.60 $0.00 04/04/2025$0.00

03/11/2024 Other Ins Paid 04/04/2025 0 $290.08 04/04/2025$148.10

04/04/2025 0 $0.00 04/04/2025Primary Adjustm$104.96

Claim # 298642 Totals : $7,308.26 $0.00$7,308.26

T., John; Claim: 298353; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: R-Hand; Date Incurred: 02/20/2024

02/26/2024 Primary Adjustm 03/26/2024 0 $25.00 $0.00 03/26/2024$5.95

02/26/2024 Primary Adjustm 03/26/2024 0 $172.00 $0.00 03/26/2024$106.58

03/13/2024 Other Ins Paid 04/12/2024 0 $301.00 04/12/2024$82.70

04/12/2024 0 $0.00 04/12/2024Primary Adjustm$178.30

03/21/2024 Other Ins Paid 04/12/2024 0 $301.00 04/12/2024$82.70

04/12/2024 0 $0.00 04/12/2024Primary Adjustm$178.30

03/20/2024 Other Ins Paid 04/12/2024 0 $158.00 04/12/2024$100.13

04/12/2024 0 $0.00 04/12/2024Primary Adjustm$9.40

03/20/2024 Primary Adjustm 04/12/2024 0 $1,410.00 $0.00 04/12/2024$1,167.91

Claim # 298353 Totals : $2,367.00 $0.00$2,367.00

$9,675.26 $9,675.26 $0.002023 Sub Total: Checking Account Totals:

B., Cole; Claim: 298642; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: L-Ankle; Date Incurred: 02/09/2024

03/25/2024 Other Ins Paid 11/12/2024 2330118765 Ochsner Clinic LLC $301.00 10/15/2024$183.01

11/12/2024 2330118765 $45.75 10/15/2024Primary Adjustm$72.24

04/23/2024 Other Ins Paid 11/12/2024 2330118770 Ochsner Clinic LLC $301.00 10/15/2024$183.01

11/12/2024 2330118770 $45.75 10/15/2024Primary Adjustm$72.24

03/06/2024 Primary Adjustm 11/12/2024 2330118769 Ochsner Medical Center $167.00 10/21/2024$101.58

11/12/2024 2330118769 $13.08 10/21/2024Other Ins Paid$52.34

03/08/2024 Primary Adjustm 11/12/2024 2330118763 Ochsner Medical Center $1,408.00 10/21/2024$1,165.91

11/12/2024 2330118763 $48.42 10/21/2024Other Ins Paid$193.67

03/11/2024 Primary Adjustm 11/12/2024 2330118766 Ochsner Medical Center $150.00 10/21/2024$84.58

11/12/2024 2330118766 $13.08 10/21/2024Other Ins Paid$52.34

03/11/2024 Other Ins Paid 11/12/2024 2330118768 Ochsner Clinic LLC $31.00 10/15/2024$18.85

11/12/2024 2330118768 $4.71 10/15/2024Primary Adjustm$7.44

03/11/2024 Other Ins Paid 11/12/2024 2330118762 Ochsner Clinic LLC $488.00 10/15/2024$296.71

11/12/2024 2330118762 $74.17 10/15/2024Primary Adjustm$117.12

03/08/2024 Other Ins Paid 11/12/2024 2330118764 Ochsner Clinic LLC $154.00 10/15/2024$93.63

11/12/2024 2330118764 $23.41 10/15/2024Primary Adjustm$36.96

03/06/2024 Other Ins Paid 11/12/2024 2330118767 Ochsner Clinic LLC $511.00 10/15/2024$297.89

11/12/2024 2330118767 $90.47 10/15/2024Primary Adjustm$122.64

03/06/2024 Primary Adjustm 11/12/2024 2330118761 Ochsner Clinic LLC $25.00 $19.00 10/15/2024$6.00

03/20/2024 Other Ins Paid 04/23/2025 2330129135 Ochsner Medical Center $2,728.00 04/15/2024$200.00

04/23/2025 2330129135 04/15/2024Primary Adjustm$1,384.00

04/23/2025 2330129135 $200.00 04/15/2024Misc. Conversion$944.00

03/20/2024 04/23/2025 2330129137 OccuNet $236.00 $236.00 04/15/2024$0.00

04/01/2024 Other Ins Paid 04/23/2025 2330129134 Ochsner Medical Center $674.00 05/10/2024$50.00

04/23/2025 2330129134 05/10/2024Primary Adjustm$338.00

04/23/2025 2330129134 $50.00 05/10/2024Misc. Conversion$236.00

04/01/2024 04/23/2025 2330129136 OccuNet $59.00 $59.00 05/10/2024$0.00

Claim # 298642 Totals : $7,233.00 $922.84$6,310.16

T., John; Claim: 298353; Activity: Men's Baseball; Diagnosis: Pain; Anatomy: R-Hand; Date Incurred: 02/20/2024

04/17/2024 Other Ins Paid 06/17/2024 2330107287 Baton Rouge Orthopaedic Clinic $504.00 05/20/2024$195.08

06/17/2024 2330107287 $55.09 05/20/2024Primary Adjustm$253.83

04/29/2024 Other Ins Paid 06/17/2024 2330107288 Baton Rouge Orthopaedic Clinic $120.00 05/20/2024$35.36

06/17/2024 2330107288 $40.00 05/20/2024Primary Adjustm$44.64

02/26/2024 Other Ins Paid 06/17/2024 2330107289 Ochsner Clinic LLC $358.00 05/20/2024$136.69

06/17/2024 2330107289 $40.00 05/20/2024Primary Adjustm$181.31

04/24/2024 Other Ins Paid 06/17/2024 2330107290 Surgical Specialy Center of Baton Rouge $1,016.00 05/20/2024$196.14

06/17/2024 2330107290 $49.04 05/20/2024Primary Adjustm$770.82

Claim # 298353 Totals : $1,998.00 $184.13$1,813.87

$9,231.00 $8,124.03 $1,106.972023 Sub Total: Checking Account FA-Guarantee Trust Life Ins

Checking Account: GTL

B., Cole; Claim: 298642; Activity: Men's Basketball; Diagnosis: Pain; Anatomy: L-Ankle; Date Incurred: 02/09/2024

03/18/2024 Phys.Therapy Primary Adjustm 09/05/2025 3053867 Ochsner Medical Center $166.00 08/19/2025$92.61

09/05/2025 3053867 $12.83 08/19/2025Disc:Alliance Contract$60.56

03/18/2024 Phys.Therapy Primary Adjustm 09/05/2025 3053867 Ochsner Medical Center $156.00 08/19/2025$87.03

09/05/2025 3053867 $12.06…