Tele: (219) 921-1196    E-mail: lmhakes@aol.com

United Square Dancers of America

Commercial General Liability and

Accident Medical Insurance Program Affiliate

Membership Fee and Insurance Annual

Flat Rate Per Member - $5.50

** Please make all checks payable to Indiana Dancers Association **

PART I - LIABILITY INSURANCE

    Limits of Protection

    Who is Covered

    Where are Claims Filed

PART II - ACCIDENT MEDICAL INSURANCE

    What are the Limits

    Who is Covered

    What is Covered

    What is not Covered

    How to Present a Claim

PART III

    Period of Coverage

    Cost of Program

Forms - (Word Format)

Application  

Club Roster

Additional Enrollments - (New members after initial Enrollment)

Other Members  -  (Club members covered by other clubs)

Sponsored Class

Special Dance Notice

Accident Report

Claims Information

Additional Information and Frequently Asked Questions

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THE TWO AREAS OF INSURANCE PROTECTION ARE

LIABILITY AND ACCIDENT MEDICAL COVERAGE

As closely as safety rules are followed, accidents will happen. Accident Medical insurance helps protect club members from financial loss due to a covered accidental bodily injury. Liability insurance protects the club and it's members and association officials from financial loss due to unforeseen incidents which may develop into litigation against members and dance organizations.

PART I - LIABILITY INSURANCE

A.  LIMITS OF PROTECTION:

$1,000,000 Combined Single Limit of liability for bodily injury and property damage each occurrence (subject to a $100 property damage deductible per claim) while participating in scheduled and sponsored dancing activities. $100,000 limit for Damage To Premises Rented to you. Nonowned/liired Car Liability Coverage is available-contact U.S.D.A. National Insurance Coordinator for application. Their address is: P.O. Box 417 Stephens, GA 30667.

B.   WHO IS COVERED:

The club and its members while participating in club or organi­zation sponsored and supervised dancing activities. Liability coverage applies in the U.S. , its territories or possessions, and Canada .

C.   WHERE ARE CLAIMS FILED:

Notify the Affiliate Insurance Chairman regarding any third party claims presented to the Club/Association. Chairman shall call U.S.D.A. National Insurance Coordinator with full descrip­tion of incident.

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PART II - ACCIDENT MEDICAL INSURANCE

A. WHAT ARE THE LIMITS:

$10,000* -- Usual and Customary Accident Medical -including, Dental

$10,000       Accidental. Death Benefit

$10,000      Accidental Dismemberment Benefit (loss of both hands, both feet, sight of both eyes, or any combi­nation thereof)

$5,000** — Accidental Dismemberment Benefit (loss of one hand, one foot, sight of one eye)

Accidental Death and Dismemberment Benefits Limitations We will not pay for a Loss caused in any way by:

1.bodily or mental infirmity or illness;

2.infection; except pyogenic or bacterial infection in a cut or wound caused by an accident;

3.  medical or surgical treatment; except for surgery which results from an accident;

4.  air travel, other than as a fare-paying passenger on a sched­uled commercial flight;

5 .war or act of war;

6 taking part in a riot or felony; this shall not include being a victim of a felony;

7. suicide; attempted suicide or intentional self-inflicted injury.

NOTE: *Accident Medical Coverage is excess to any other valid and collectible medical insurance covering the same accident Coverage provided for covered medical expenses incurred with­in 52 weeks of the accident up to $10,000 for all eligible expenses as stated in the Policy.

**If more than one of specified losses results from the same accident, only one amount, the largest, will be paid.

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B.  WHO IS COVERED:

Club members will be insured while participating in any regu­larly scheduled and sponsored dancing activity worldwide, including group travel (10 or more dub members) in a vehicle commercially licensed for transportation of passengers and operated by a person holding a valid operator's license for such vehicle, while being transported to or from a covered danc­ing activity

C. WHAT IS COVERED:

Accidental bodily injury sustained by an insured person while participating in dancing activities sponsored and supervised by a recognized club or organization.

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D.   WHAT IS NOT COVERED:

-Expenses for treatment on or to the teeth, except for treatment resulting from injury to natural teeth;

-Eyeglasses, hearing aids, and examination for the prescription or fitting thereof;

-Suicide, attempted suicide or intentionally self-inflicted injury; -Injury due to participation M a riot

-Loss resulting from air travel, except as a fare-paying passen­ger on a commercial airline;

-Injury or sickness resulting from declared or undeclared war; -injury or sickness while in the armed. forces of any country;

-Injury or sickness covered by any workers' compensation or occupational disease law,

-Treatment provided in a governmental hospital unless the insured is legally obligated to pay such charges;

-Infections, except pyogenic or bacterial infections caused wholly by a covered injury' sickness;

-Hernia, unless it results from a covered injury;

-The insured's being intoxicated or under the influence of any narcotic unless administered on the advice of a physician; -Pre-existing Conditions;

-Claims occurring while dancing at private residences; -Services normally provided without charge by you or your employees;

-Claims occurring while parachuting or hang-gliding; or injury sustained while traveling in or on any two or three-wheeled motor vehicle operated by a person who does not hold a valid operator's license;

-Cosmetic surgery.

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B.  HOW TO PRESENT A CLAIM:

In the event of a covered accident, immediately notify the Club Representative or a responsible officer of the Club. A Proof of Loss form (available from the Club Representative) must be completed. The front is to be filled in and signed by the Club official and the claimant; the back is to be completed by the attending physician. Notice of injury is to be forwarded to the U.S.D.A. National Insurance Coordinator within twenty (20) days, or as soon thereafter as reasonably possible to P.O. Box 22 , Tucker, GA 30085-0022.

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PART III

A.  PERIOD OF COVERAGE:

The policy term is January 1 through December 31. Coverage becomes effective for individual clubs under the policy on the day the application and premium for insurance is received by the U.S.DA. National Insurance Coordinator.

B.  COST OF PROGRAM:

$5.50 Flat Rate Per Member per policy term or any part there­of. Liability totes would be substantially higher if the Accident Medical portion were not to be included in this program.

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THIS IS A SUMMARY OF COVERAGE- NOT A CONTRACT - Policy located at www.usda.orgfinsuranc.htm

For complete provisions, policy coverages, terms, conditions & exclusions, please refer to the Policy at www.usda.org/insuranc.htm. If there any conflict between the provisions of this brochure and those of the Policy, the provisions of the Policy will govern.

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ADDITIONAL INFORMATION

1.        Roster of club members is required at time of premium payment.

2.         If a club member belongs to more than one club, they pay only one enrollment fee.

3.         If club members leave the club and fail to join another participating club within 30 days, their insurance coverage ceases.

4.       Students (taking lessons for the first time or coming back after an extended absence) in beginning dance classes sponsored by an insured club are covered by insurance at no additional cost to the club. A club must submit a roster with a beginning and ending date for the class. Students will only be covered while attending classes for nine (9) months.

5.          The minimum number of members for a club to obtain U.S.D.A. Insurance will remain at 8.  The minimum amount you will submit for any club will be $45.00.  The minimum amount is not based on a minimum membership of 8 but on the number of members that your club is paying for.  

Example 1:  Your club membership is 15 with 4 members Insured Through Another Club (ITAC).  You would have 11 paying members and your fee is greater than $45.00.

Example 2:  Your club membership is 15 with 6 ITAC members for a total of 9 paying members.  You would submit $49.50 for this club.

6.         The policy does not cover the caller/cuer and his or her equipment when he or she is calling.

7.       An honorary member or caller/cuer member of a club is covered by this policy when attending a dance as a dancer and an enrollment fee has been paid for each dancer.

8.       Name, street address, city, state and zip code of each facility anticipated to be used during the year will be required when effecting coverage.

9.       Approximately 45 days lead-time is required to obtain a certificate of insurance for a particular facility not on the original policy.

10.   Provides $100,000 limit for damage to premises rented to you and caused by an insured dance organization.

11.   Picnics, camp outs, snow trips and other non-dancing activities are not covered by this insurance. Special, one-event accident medical insurance must be separately arranged.

12.   Claims must be filed, whenever possible, within 20 days from the date of the accident with medical bills attached. Mail claims to the Federation/Association insurance chairman.

13.   The death and dismemberment benefit applies regardless of any other insurance the member may have. Death must result from a covered accident at a bonafide club or organization dancing activity or an accident during the course of group travel (see definition of group travel).

14.   Coverage is excluded while dancing at private residence.

15.   Complete the When, Where, Why and How accident information form within 48 hours.

16.   Any addition to the club roster after the initial enrollment for the current year will require an enrollment fee per dancer.

17.   Notification of event form is necessary if a club dances at a facility which is not their regular dance location. If a certificate of insurance is not issued for a facility, there is no liability coverage for the facility being used. A new insurance certificate is only needed if requested by the new facility.

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