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• USA AMATEUR BOXING FEDERATION FACT SHEET SPORTS ACCIDENT POLICY #50150-07 WHO IS COVERED? All registered members of USA Amateur Boxing Federation, participating in activities sponsored and supervised by USA Amateur Boxing Federation. There is one membership level: Class I All registered members of USA/ABF whose names are on file with the Policyholder. WHAT IS COVERED? o Injuries that occur at practices and competitions sanctioned or sponsored, and supervised by the USA Amateur Boxing Federation. Coverage is provided, to the limits of the policy, for medical/dental expenses and death/dismemberment as a result of a qualifying injury. o Sickness is not covered. o Re-injury is considered a pre-existing condition. Potentially chronic injuries, such as dislocating shoulders will be examined -carefully because they have a tendency to recur. BENEFITS Summary... o Class I Practice:. Accidental Death and Dismemberment $10,000 The full amount is payable upon death or a scheduled amount for a variety of dismemberment (loss of a limb or loss of complete use of that limb). Medical Expense $1,000 The total payable benefit per accident. See the definition of EXCESS below. Dental Expense $1,000 The total payable benefit per accident. See the definition of EXCESS below. There is a $100 deductible per accident before any benefits are payable. Physical Therapy/Chiropractic Benefit (annual maximum) $500 o Class II Sanctioned Events: Accidental Death and Dismemberment $10,000 The full amount is payable upon death or a scheduled amount for a variety of dismemberment (loss of a limb or loss of complete use of that limb). Medical Expense $10,000 The total payable benefit per accident. See the definition of EXCESS below. Dental Expense $1,000 The total payable benefit per accident. See the definition of EXCESS below. There is a $100 deductible per accident before any benefits are payable. Physical Therapy/Chiropractic Benefit (annual maximum) $500 Excess Coverage... All Benefits are payable on an EXCESS BASIS. This means that any other insurance—your personal policy, an employer group policy, a parent's policy under which you are named--must pay the charges on each bill (that are payable under that policy's contract) before this insurance will pay. Proof of these payments must be submitted to the claims payor. The deductible is met by... o Personal and/or other insurance payments totaling $100 for the injury for which you are submitting the claim. If you have no other insurance coverage you will be responsible for the first $100 in medical and/or dental expenses. o Meeting the annual deductible for your group or any other insurance does not satisfy this requirement. Basis for payment... "Usual and customary" or "reasonable and customary" rates. Your doctor's billing clerk will understand these terms. You will be responsible for any amount that exceeds the total payable benefit. CLAIM FORMS SHOULD BE REQUESTED FROM: Your coach or Local Boxing Committee. If you are unable to obtain forms through these persons, contact: USA Amateur Boxing Federation, 1750 E. Boulder, CO SPGS., CO 80909 CLAIM FORMS SHOULD BE SENT TO: Your Local Boxing Committee (LBC)