Insured-WALTON_COUNTY_PROBATION.pdf

P.O. Box 2338 Fort Wayne, IN 46801-2338 800-637-4757 Fax: 260-459-5866 www.kandkinsurance.com

California License #0334819

COV2

insuring the world’s fun ®

02/04/2026

WALTON COUNTY PROBATION

571 E. NELSON AVE SUITE 201

DEFUNIAK SPRINGS, FL 32433

Re: Policy Number: SRPO0000018144604

WALTON COUNTY PROBATION

Dear Sir/Madam, Thank you for providing the opportunity for K&K Insurance to serve your specialized insurance needs.

Enclosed is your insurance coverage document(s). Please carefully review coverages, limits and exclusions and contact me immediately if changes or additions are necessary. An additional premium or a credit may occur for any changes.

Premium should be remitted to our office in accordance with the payment schedule upon which we have agreed.

Sincerely, Erica Proegler Underwriter

Enclosure

(PA)1029_AXIS_05-20

Group Accident Claims 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN 46801

PH (800) 237-2917

Fax: (312) 381-9077 http://www.kandkinsurance.com KK.PAClaims@kandkinsurance.com

K&K

INCIDENT

REPORT

(PLEASE PRINT)

NATURE O BODILY INJURY O PROPERTY DAMAGE O OTHER:

TIME &

PLACE OF

INCIDENT

DATE: TIME: O AM O PM

EVENT NAME:

EVENT TYPE: SANCTIONED BY:

LOCATION:

HAPPENED

TO

NAME: SSN:

DATE OF BIRTH: SEX: O Male O Female PHONE: ( )

ADDRESS:

CITY: STATE: ZIP:

EMAIL ADDRESS:

FUNCTION AS: O ATHLETE O PARTICIPANT O VOLUNTEER O SPECTATOR O BYSTANDER

O OFFICIAL O OTHER:

APPARENT

INJURY OR

DAMAGE

BODY PART:

CONDITION: (Laceration, Concussion, Sprain, Fracture, Etc.):

O ON SITE CARE ONLY, BY O PHYSICIAN O EMT O TRAINER O OTHER:

O AMBULANCE, TAKEN TO: CITY:

O FATALITY:

OCCASION WHAT WAS THE SITUATION AND EXACT LOCATION AT THE TIME OF THE INCIDENT?

INCIDENT

DESCRIP-

TION

DESCRIBE WHAT HAPPENED:

WITNESSES

(If known)

NAME: F NAME: F

ADDRESS: ADDRESS:

PHONE: ( ) PHONE: ( )

INSURED NAME OF INSURED: POLICY#:

CLUB NAME: PHONE:

CITY: STATE:

INSURED

REPRESENT-

ATIVE

O COACH O OFFICIAL O TRAINER O PROMOTER O TEAM/LEAGUE REPRESENTATIVE

O OTHER:

NAME: PHONE: ( )

TITLE: ORGANIZATION:

SIGNATURE: DATE:

COMPLETE ALL SECTIONS AND FAX OR MAIL IMMEDIATELY TO:

K&K INSURANCE GROUP, INC., P.O.BOX 2338, FORT WAYNE, IN 46801-2338

THIS FORM MUST INCLUDE THE INSURED NAME, POLICY NUMBER, AND SIGNATURE OF THE

INSURED/REPRESENTATIVE BEFORE RETURNING OR PROCESSING MAY BE DELAYED.

RPO0000018144604

http://www.kandkinsurance.com/

Group Accident Claims 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN 46801

PH (800) 237-2917

Fax: (312) 381-9077 http://www.kandkinsurance.com KK.PAClaims@kandkinsurance.com

PARTICIPANT ACCIDENT

OTHER INSURANCE FORM

Insured Name:

Policy Number:

IT IS IMPORTANT THAT ALL INFORMATION REQUESTED ON THIS CLAIM FORM BE FURNISHED.

OMISSION OF VITAL INFORMATION WILL CAUSE DELAY IN CLAIM PROCESSING.

TO BE COMPLETED BY INJURED PERSON OR PARENT

PART II

MEDICAL BENEFITS UNDER THIS POLICY MAY PROVIDE PRIMARY, EXCESS OR A COMBINATION OF BOTH COVERAGES. UPON RECEIPT OF THIS CLAIM FORM, AN ACKNOWLEDGEMENT LETTER WILL BE SENT TO YOU ADVISING WHAT SPECIFIC BENEFITS YOU ARE ENTITLED

TO.

IF THE MEDICAL BENEFIT IS EXCESS, YOUR CLAIM SHOULD BE SUBMITTED TO THE INSURANCE COMPANY PROVIDING COVERAGE TO YOU THROUGH YOUR OWN OR YOUR PARENT’S PERSONAL HEALTH PLAN, YOUR EMPLOYER OR GOVERNMENTAL HEALTH PLAN. AFTER OTHER INSURANCE BENEFITS HAVE BEEN SUBMITTED, YOU SHOULD FORWARD A COPY OF THE OTHER INSURANCE COMPANY’S EXPLANATION OF BENEFITS AND THE CORRESPONDING ITEMIZED MEDICAL STATEMENTS. IF YOUR INSURANCE COMPANY DENIES

BENEFIT, SEND A COPY OF THEIR DENIAL.

WE WILL NOT PROCESS YOUR CLAIM WITHOUTH EMPLOYER INFORMATION. IT IS IMPERATIVE THAT WE RECEIVE ALL DATA REQUESTED.

TIMELY RECEIPT OF REQUESTED INFORMATION WILL HELP EXPEDITE PROCESSING OF YOUR CLAIM.

INJURED PERSON: SPOUSE’S NAME:

(if applicable):

FATHER’S NAME: MOTHER’S NAME:

(if injured is a minor) (if injured is a minor)

EMPLOYER NAME EMPLOYER NAME

EMPLOYER ADDRESS EMPLOYER ADDRESS

CITY: STATE: ZIP: CITY: STATE: ZIP:

PHONE: PHONE:

GROUP INSURANCE COMPANY: GROUP INSURANCE COMPANY:

POLICY NUMBER: POLICY NUMBER:

INSURANCE COMPANY ADDRESS: INSURANCE COMPANY ADDRESS:

CITY: STATE: ZIP: CITY: STATE: ZIP:

DATE OF BIRTH: DATE OF BIRTH:

SIGNATURE: SIGNATURE:

QUESTIONS REGARDING INCOME ARE ONLY APPLICABLE IF POLICY AFFORDS WEEKLY INDEMNITY

BENEFITS.

REGULAR WEEKLY INCOME: INCOME LOST PER WEEK DUE TO INJURY:

ON WHAT DATE DID YOU, OR DO YOU EXPECT TO, ON WHAT DATE DID YOU, OR DO YOU EXPECT TO, RESUME RACING

RESUME WORK? AND/OR PARTICIPATE IN A RACING EVENT?

I WAIVE ANY PROVISION OF THE LAW TO THE CONTRARY AND HEREBY AUTHORIZE K&K OR ITS REPRESENTATIVES TO FURNISH TO ANY HOSPITAL, PHYSICIAN OR OTHER PERSON WHO HAS ATTENDED ME, AND MY INSURANCE CARRIER, ANY AND ALL INFORMATION WITH RESPECT TO THE ACCIDENTAL INJURY FOR WHICH I AM CLAIMING INSURANCE BENEFITS.

I WAIVE ANY PROVISION OF LAW TO THE CONTRARY AND HEREBY AUTHORIZE AND HOSPITAL, PHYSICIAN OR OTHER PERSON WHO HAS ATTENDED ME, AND MY INSURANCE CARRIER OR EMPLOYER, TO FURNISH TO K&K OR ITS REPRESENTATIVES ANY AND ALL INFORMATION WITH RESPECT TO ANY SICKNESS OR INJURY, MEDICAL HISTORY, CONSULTATION, PRESCRIPTIONS, OR TREATMENT, AND COPIES OF ALL HOSPITAL, MEDICAL, OR INSURANCE RECORDS INCLUDING, BUT NOT LIMITED TO, INFORMATION REGARDING OTHER INSURANCE COVERAGES. I AGREE THAT A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AS

THE ORIGINAL.

I UNDERSTAND THIS AUTHORIZATION IS NECESSARY TO FACILITATE THE OBTAINING AND PROVIDING OF INFORMATION NEEDED TO

QUICKLY PROCESS MY CLAIM.

SIGNED: DATE:

Please Note: If injured person is a minor, signature must be of parent or legal guardian.

http://www.kandkinsurance.com/

PARTICIPANT ACCIDENT

INSURANCE CLAIM FORM

INSTRUCTIONS

(NOTE To the Participant/Parent/Guardian: Report and Claim Form will be returned if not fully completed and signed.)

Basic Procedures for Submitting the Incident Report and Participant Accident Insurance Claim Form

1. The insurance coordinator, coach or league representative, official, trainer, promoter will complete the incident report (front). If the policy provides accident medical coverage and the injured party was an event participant, the form should be given to the participant or parents to complete the participant accident medical insurance claim form (Part II).

2. The participant or participant’s parents/guardian will complete the form, detach it from the instruction page, and forward it to K&K Insurance Group, Inc.

3. IF CLAIM INVOLVES INJURY TO A SPECTATOR OR PROPERTY DAMAGE, ONLY THE

INCIDENT REPORT NEED BE COMPLETED.

To the Participant/Parent/Guardian:

Attach current itemized physician, hospital, or other provider’s bills for accident medical expenses being claimed as well as the primary carrier’s Explanation of Benefits showing their payments and denials. These bills must show the patient’s name, condition (diagnosis), type of treatment given, date the expense was incurred and the charges made.

MAIL TO:

K&K INSURANCE GROUP, INC.

Group Accident Claims Department

P.O. Box 2338 Fort Wayne, Indiana 46801-2338

(800) 237-2917 Fax: (312) 381-9077

Email: kk.paclaims@kandkinsurance.com

IMPORTANT NOTICE

• In General, and specifically for residents of Arkansas, Illinois, Louisiana, Rhode Island and West Virginia: 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.

• For Residents of Alabama: Any person who knowingly present 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 restitution fines and confinement in prison, or any combination thereof.

• For residents of 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.

• For residents of the 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.

• For residents of 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.

• For residents of 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.

• For residents of Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an Insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

• For residents of Oregon: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

• For residents of Maryland: Any person who knowingly of willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

• For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

• For residents of 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.

• For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files and application for insurance or statement of claim 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, 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.

• For residents of Ohio: Any person who, with intent to defraud of knowing that he is facilitating a fraud against an Insurer, submits a false or deceptive statement is guilty of Insurance fraud.

• For residents of 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.

• For residents of Pennsylvania: 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 purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

• For residents of Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

• For residents of Virginia: Any person who with the intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a false or deceptive statement may have violated state law.

[AXIS_FRAUD 0220]

Dear Participant: If you have an appointment with a doctor as a result of a sport related injury, please show this document to the doctor’s insurance secretary. You should be identified as a member of the following preferred provider networks and/or their affiliates.

Dear Doctor or Provider: This document indicates that this patient is a participant in the following preferred provider networks and/or their affiliates.

INSTRUCTIONS FOR COMPLETING THE ACCIDENT INSURANCE FORM

TO THE INJURED PERSON/PARENT/GUARDIAN

To the injured person/parent/guardian:

Complete part II of this claim form. Attach current itemized physician, hospital, or other provider’s bills for accident medical expenses as well as the primary carrier’s explanation of benefit showing their payment and denial. These bills must show the patient’s name, condition (diagnosis), type of treatment given, date the expense was incurred, and the charges made. Return this form to K&K Insurance Group, Inc. Please note: Claim forms will be returned if not fully completed and signed. Omission of vital information will cause a delay in claim processing.

BACC-005-0909 1 KandK_RENEWCW20240515

AXIS INSURANCE COMPANY

(A Stock Company)

(Herein called the Company)

Administrative Office:

10000 Avalon Blvd., Suite 200

Alpharetta, GA 30009

Home Office:

233 South Wacker Drive, Suite 4930

Chicago, IL 60606

BLANKET ACCIDENT POLICY/CERTIFICATE

AMENDMENT

POLICY AMENDMENT NO. 04

POLICY RENEWAL

POLICYHOLDER: WALTON COUNTY PROBATION

POLICY NUMBER: SRPO0000018144604

POLICY EFFECTIVE DATE: March 1, 2026

POLICY ANNIVERSARY: 03/01

STATE OF ISSUE: Florida

This Amendment is attached to and made part of the Policy effective March 1, 2026 at 12:01 AM, Standard Time. Any changes in coverage apply only with respect to covered losses that occur on or after that date. Any changes in premium apply as of the first premium due date on or after the effective date of this Amendment.

It is hereby understood and agreed the Policy is renewed for a period of one year, commencing on March 1, 2026 and ending February 28, 2027.

Renewal Premium: $2,381.40

This Amendment expires concurrently with the Policy and is subject to all of the provisions, limitations and conditions of the Policy except as they are specifically modified by this Amendment.

The President and Secretary of AXIS Insurance Company witness this Amendment:

Secretary President

BACC-005-0909 1 KandK_POLCHG_CW_20211119

AXIS INSURANCE COMPANY

(A Stock Company)

(Herein called the Company)

Administrative Office:

10000 Avalon Blvd., Suite 200

Alpharetta, GA 30009

Home Office:

111 South Wacker Drive, Suite 3500

Chicago, IL 60606

BLANKET ACCIDENT POLICY/CERTIFICATE

AMENDMENT

POLICY AMENDMENT NO: 04

POLICYHOLDER: WALTON COUNTY PROBATION

POLICY EFFECTIVE DATE: March 1, 2026

POLICY NUMBER: RPO0000018144604

POLICY ANNIVERSARY DATE: 03/01

STATE OF ISSUE: FL

This Amendment is attached to and made part of the Policy effective March 1, 2026 at 12:01 AM, Standard Time. Any changes in coverage apply only with respect to covered losses that occur on or after that date. Any changes in premium apply as of the first premium due date on or after the effective date of this Amendment.

I. It is hereby agreed and understood that the “Full Excess Medical Expense” and Other HealthCare Plan Reduction” Benefits are deleted from the Policy and replaced with “Primary Medical Expense” Benefit.

A. The “Full Excess Medical Expense” and “Other Health Care Plan Reduction 50%” under the ACCIDENT MEDICAL BENEFIT, Scope of Coverage Applicable to Accident Medical Benefits in the BENEFITS section of the Policy SCHEDULE OF BENEFITS is deleted and replaced with “Primary Medical Expense” as follows:

ACCIDENT MEDICAL BENEFIT

Scope of Coverage Applicable to Accident Medical Benefits

Any benefit limits and benefit percentages apply, unless otherwise specified, on a per Insured Person – per Covered Loss basis. Any applicable Deductibles must be satisfied within the time periods specified before benefits are payable.

Primary Medical Expense

(Refer to Policy Schedule of Benefits for the Primary Medical Expense Benefit coverage amounts)

B. The DESCRIPTION OF BENEFITS section of the policy is amended by the deletion of Full Excess Medical Expense benefits in its entirety and replaced with the following:

Primary Medical Expense The Company will pay the Medically Necessary Covered Expenses without regard to any Other Health Care Plan the Insured Person may have, after any applicable Deductible is satisfied.

BACC-005-0909 2 KandK_POLCHG_CW_20211119

This Amendment expires concurrently with the Policy and is subject to all of the provisions, limitations and conditions of the Policy except as they are specifically modified by this Amendment.

The President and Secretary of AXIS Insurance Company witness this Amendment:

Secretary President