Sigma Gamma Rho Sorority, Inc.

SIGMA GAMMA RHO SORORITYTHE GENERAL LIABILITY INSURANCE PROGRAMThe following description is a summary only and is not intended to serve as a substitute for the actualinsurance contract.Sigma Gamma Rho Sorority insurance program provides Blanket Public General Liability Coverage of$4,000,000 per occurrence with a $ 11,000,000 general aggregate per location for all participatingchapters. (Types of coverage are included at the end of this section).The coverage is for bodily injury and third party property damage. The Named Insured and those entitiesand individuals listed under “Who is Covered” on the next page are protected, subject to certain policyexclusions and limitations, under the policy from claims brought due to bodily injury and/or propertydamage resulting from Sorority operations and activities. This policy also protects against claims arisingout of personal and advertising injury as indicated below under number 3.It must be understood that our coverage is for general public liability. It is not accident insurancecovering members and membership selection candidate for injuries sustained on the chapterpremises and/or in chapter activities. Liability insurance is not a substitute for medical insurance.Furthermore, it is not Workers' Compensation insurance which may be required for Sorority employees.Primary Insurer:Admiral Insurance CompanyPolicy Period: March 28, 2009 to March 28, 2010Policy Number:CA00000680105Primary Insurer:James River Specialty Insurance CompanyPolicy Period: March 28, 2009 to March 28, 2010Policy Number: 000307241Sigma Gamma Rho Sorority Coverage includes:1. COMMERCIAL GENERAL LIABILITYCovers liability arising out of Sorority premises and operations.2. PRODUCTS/COMPLETED OPERATIONS LIABILITYCovers preparation and consumption of food and beverages.3. PERSONAL INJURY & ADVERTISING INJURYCovers libel, slander, defamation of character, false arrest, detention, malicious prosecution,wrongful entry or eviction, invasion of privacy.4. CONTRACTUAL LIABILITY COVERAGEUnder certain circumstances, the liability coverage of Sigma Gamma Rho Sorority insurancecontract is extended to protect other parties with whom a Sigma Gamma Rho Sorority chaptermay enter into a contractual agreement. No contract should be signed by any entity/chapter ofSigma Gamma Rho Sorority, without complete understanding of liabilities being assumed andinsurance coverage, if any, that is provided. When any questions arise, please contact yourchapter advisor or the Headquarters of Sigma Gamma Rho.5. WATERCRAFT LIABILITYCovers hired and non-owned boats/watercraft providing it is less than 26 feet in length.6. INCIDENTAL MEDICAL MALPRACTICECovers liability that arises against an insured chapter or an individual who provides emergencymedical care for injuries on or off our premises4SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

7. DAMAGE TO PREMISES YOU RENT$250,000 damage to premises you rent. This is not a substitute for property insurance. Damageto premises you rent liability coverage provides coverage for liability arising against your Sororityout of fire damage to a non-owned premises rented for any period of time as well as otherdamage to a premises you rent for 7 or less days.8. WORLDWIDE COVERAGECoverage worldwide for suits brought in the United States.9. HOST LIQUOR LIABILITYProvides coverage when providing alcoholic beverages at no charge to those of legaldrinking age. If you are found to be in the practice of manufacturing, distributing,selling, serving or furnishing alcoholic beverages, or if minors are involved, your coverage andprotection is jeopardized.Limits of CoverageGeneral Liability:$1,000,000 Bodily injury & property damage Combined Single Limit.$2,000,000 Policy Aggregate per location/chapter.Deductible: $2,500 per occurrenceUmbrella Liability:$3,000,000 Bodily injury & property damage Combined Single Limit.$9,000,000 Policy Aggregate per location/chapter.Who is covered?The insurance coverage will pay claims up to $4,000,000 per occurrence for the following organizationsand/or people:A. The local undergraduate and graduate chapter that is chartered and recognized by theSorority when it obeys the laws of the institution, city, county, state and country in which itoperates and the policies of Sigma Gamma Rho. Undergraduate and Graduate chapterofficers, executive committee, committee chairman and members while performing the dutiesof their elected or appointed positions within the organization.B. All volunteer advisors while performing the duties of their appointed or elected positions.C. The house corporation while the directors are performing their duties as corporate officers.D. Alumni Associations and chapter related educational foundations, its officers, and appointedvolunteers while performing the services of their positions.Who is not covered by this policy?A. Any individual member, alumnus, trustee or advisor who is performing tasks outside of herresponsibility (i.e. spontaneous social function planned by an individual member, chapteradvisor consuming alcohol with undergraduates, hazing of members, etc...)B. Any member who’s illegal or intentional actions result in death or injury to an individual orproperty damage.C. Members' parents or family members and guests of chapter members.D. College/University administration (see Adding Additional Insureds below).5SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

Adding Additional InsuredsAdditional Insureds may be added to this policy. Such Additional Insureds may be your landlord, college,university and/or proprietor from whom the chapter may be renting property for a special event.Please submit the Additional Insured Request Form on page 23 to: Sigma Gamma Rho SororityHeadquarters, 1000 Southhill Drive, Suite 200, Cary, NC 27513-8630 fax (919)573-9119 at least (30)thirty days prior to the date it is needed.Upon review and approval of the Additional Insured request by Sigma Gamma Rho Sorority and theinsurance carrier, a certificate of insurance will be issued by Willis HRH, with the original forwarded to theAdditional Insured and a copy to the Headquarters.Proper function planning is critical to completing any Special Event in a safe manner! Pleaseutilize the enclosed Special Event Checklist to assist with your event planning.What Does Our Coverage Not Include?A. Any claim of bodily injury and/or property damage from an incident resulting when:1. An illegal act was committed.2. An intentional act was committed.3. A contract made by the chapter is broken.4. There is any discharge, release or escape of smoke, vapors, soot, fume, acids, toxicchemicals, etc... upon land, the atmosphere or any water course or body of water.5. An employee is hurt on the job. Workers' Compensation coverage must be purchased.B. Any claim of property damage to property owned by, rented by, used by, or cared for by the chapter.For example, the chapter rents a portable generator for an outdoor function, and while it is in the care,custody and control of the chapter, it is damaged and the lesser holds the chapter responsible andliable. No coverage is available under Sigma Gamma Rho Sorority liability insurance contract. Theonly exception would be a premise rented for 7 or less days in which the "$ 250,000 Damage toPremises You Rent" limit would apply.Legal and Illegal ActivitySimply stated, no insurance policy in the world provides coverage for violations of the law. Sigma GammaRho Sorority insurance program is no exception to this rule. The key points to understand are:• Compliance with federal, state, local and institutional (college or university) laws andregulations is required.• Compliance with all regulations and policies of Sigma Gamma Rho Sorority is required.Those individuals who choose to violate these rules may void the protection for themselves under SigmaGamma Rho Sorority insurance program. Every effort has been made to avoid their actions fromjeopardizing the other members, other entities, or other named insureds protected by Sigma Gamma RhoSorority program. The following brief examples are intended to provide illustration and do not representlegal advice.A. With the broad awareness of its membership, the chapter serves alcohol to a minor in violation ofthe law at a chapter sponsored function. In the event of an injury, claim or lawsuit, those personsfound to be in violation of the law and/or Sigma Gamma Rho Sorority (in this case the entirechapter) most likely would be without insurance protection. The other named insureds would beprotected (i.e. Sorority, or volunteer alumni).B. Two of the members of a 65-person chapter cause injury to someone in connection with a hazingincident. This activity was unauthorized and done secretly without the knowledge of the chapter,and strictly against chapter policy. In the event of an injury, claim or lawsuit, those persons (in this6SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

LAWSUITSThere will be occasions when lawsuits may be served on a member of your chapter. As there is only alimited time to answer a lawsuit, the following procedure applies:a. Treat any potential or actual claim or lawsuit as a high priority item and immediately notifyNational Headquarters by phone.b. Utilizing the enclosed incident reporting form, note all relevant information.c. Forward the suit or incident report via fax to Executive Director, Sigma Gamma RhoHeadquarters, at (919)573-9119. If you do not have access to a fax machine, overnight thepapers to Sigma Gamma Rho, 1000 Southhill Drive, Suite 200, Cary, NC 27513-8630. It is veryimportant the claim or lawsuit be sent immediately.GENERAL LIABILITY CLAIMSGeneral Liability claims can be numerous and usually arise out of activities of a chapter which causebodily injury, property damage or personal injury to an individual. They will more than likely involvedamage or injury to someone other than an employee or an officer of the Sorority.While on the scene, if possible, get names, addresses and phone numbers of all parties involved, as wellas any witnesses to the accident. Immediately complete the attached incident reporting form and submit.What should be reported?Report bodily injury to anyone other than an employee and any property damage for which there is thepossibility a claim may be made against Sigma Gamma Rho Sorority. Complete the enclosed incidentreporting form which will provide the needed information regarding the claim. If you question whether toreport a potential claim, report it!It is imperative all losses or incidents be reported immediately to Sigma Gamma Rho Sorority (see phonenumbers and address on below). The Executive Director of Sigma Gamma Rho Sorority is responsible forproviding the initial report of the claim to Willis HRH. (see phone numbers and address on below). Oncethe claim report is sent to Willis HRH you will likely be contacted directly by them or an insurancecompany representative to discuss the incident. If you are unable to obtain all necessary details when firstnotified of any incident, still report any known facts.Success or failure of Sigma Gamma Rho’s insurance program and our ability to obtain reasonably pricedinsurance is contingent upon accurate and timely reporting. It is incumbent upon you as a member ofSigma Gamma Rho Sorority to report all known facts regarding bodily injury, property damage, orpersonal injury arising out of Sigma Gamma Rho Sorority activities in a timely manner.SIGMA GAMMA RHOINCIDENT/CLAIM REPORTINGSigma Gamma Rho SororityRachel MorrisExecutive DirectorSigma Gamma Rho1000 Southhill Drive, Suite 200Cary, NC 27513-8630.Phone: (888)747-1922Fax: (919)573-9119executivedirector@sgrho1922.orgWillis HRH.ATTN: Steve Wilson, Mgr. of Claims and Loss Control12231 Emmet Street Suite 5Omaha, NE 68164(402) 498-0464 Phone or (800) 736-4327(Ext. 209)(402) 492-8421 Facsimile or (800) 328-0522swilson@willis.com or www.willissorority.comAlternate: Mick McGill Client Advocate(800) 736-4327(Ext. 229),mmcgill@willis.comSIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL9

OPTIONAL INSURANCE COVERAGEChapter Property Insurance ProgramIf a chapter of Sigma Gamma Rho Sorority owns a physical plant or building, there is no coveragefor damage to the building under the general liability policy for Sigma Gamma Rho Sorority. TheFraternal Property Management Association Insurance Program is voluntary and open for participation ofany chapter of Sigma Gamma Rho. If your chapter wishes to be provided a coverage and premiumproposal for the property program, please see the end of this section for details.The property program provides all risk coverage insuring the building, contents, business income (loss ofrents), extra expense, and boiler and machinery of property owned or leased by the local chapter orhousing corporation. It must be understood, however, that this coverage does not insure the belongingsof the individual members of the chapter. Each chapter member must ensure that their personal propertyis covered by other coverage.How does a chapter participate in the property program?If your chapter is interested in receiving a coverage and premium proposal, please have an officerrequest a coverage and premium proposal from Willis HRH, 12231 Emmet Street Suite 5, Omaha, NE68164, Attn: Tiffanie Havelka or email her at thavelka@willis.com. Jen can be reached at 800-736-4327Ext. 217, or you can use the website www.willissorority.com and go to FPMA Property Program buttonand fill out either the participation application in the drop down or the Fraternal Property ManagementAssociation automated application.Workers' Compensation CoverageThe Insurance Program of Sigma Gamma Rho does not provide Workers' Compensation Coverage forchapter employees. It is the duty of each house corporation to make certain they are familiar with theirState laws and requirements to carry Workers' Compensation Coverage for employees of the Chapter.Each State provides a State Assigned Risk Pool that can insure the Workers' Compensation exposures ofthe Chapter. The State Assigned Risk Pool can be accessed by contacting a local insurance agent orWillis HRH, your insurance broker, to obtain coverage. It is important to note that in addition to payrollspaid to a chapter cook and housemother, subsidized housing provided to chapter members in exchangefor service in a position (i.e. house manager, kitchen steward, chapter officer) is also considered payrolland if injured, the individual likely has the right to recover damages under the Workers' Compensationlaws of your State. We will work with you to help you place this coverage only if we also place theproperty coverage for your location.All questions can be directed to your Client Manager Ms. Terri Simmerman, Willis HRH, Telephone #(402) 498-0464 (ext. 213), (800) 736-4327, Fax # (402) 492-8421, e-mail: tsimmerman@willis.com.11SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

APPENDIX12SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

Sigma Gamma Rho SororityINCIDENT/CLAIM REPORTING FORMWhen an incident arises at the chapter causing bodily injury or property damage to any person, thefollowing information must be obtained immediately. This report is being prepared for submission to aSigma Gamma Rho General Counsel, so please be thorough. Do not withhold reporting an incident toobtain all required information. Because timeliness is of the essence, report it immediately and send acopy within 24 hours to the National Headquarters of Sigma Gamma Rho Sorority, 1000 Southhill Drive,Suite 200, Cary, NC 27513-8630. If the bodily injury is of a serious nature, a telephone call should alsobe made. Phone: (888)747-1922.Chapter Name:________________________ Date of Incident:_____________________________Address:______________________________ Injured Party:________________________________City, State, Zip:________________________ IP Address:_________________________________Phone #:______________________________ IP City, State, Zip:____________________________Chapter President:______________________ IP Phone #:_________________________________Chapter Advisor:_______________________ House Corp President:________________________CA Address:__________________________ _ HC President’s Address:_______________________CA Phone#:___________________________ HC President’s Phone #:_______________________Witnesses & Phone #'s:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Did Incident Happen Off Premises? (Leased or Rented) Yes or NoIf yes, Owner's Name______________________ Owner's Phone #:______________________________Owner's Address:______________________________________________________________________Police Investigation? Yes or NoName of Agency & Case #:______________________________________________________________Description of Injury & Where Was Injured Party Taken:________________________________________________________________________________________________________________________________________________________________________Description of What Happened (What, When, Where, How):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Form Completed by (Name, Title, Telephone #, E-mail Address):________________________________________________________________________________________________________________________________________________________________________Please utilize the back side of this form if you should run short of room.13SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

HAZING POLICYHAZING IS WRONG, PROHIBITED AND UNAUTHORIZEDHazing is any activity which causes or threatens to cause emotional or physical injury,or which causes emotional or physical discomfort, embarrassment, harassment, orridicule.By way of example, such prohibited activities and situations include, but are not limitedto, blindfolding; hollering at or berating people; personal servitude; running errands orperforming maid services; activities likely to cause fatigue; physical and psychologicalchallenges; treasure or scavenger hunts; wearing apparel which is conspicuous and notnormally in good taste; engaging in stunts, pranks, degrading or humiliating games andactivities; late work sessions; physical or emotional assaults; drinking games; use ormisuse of alcohol during pledge or initiation activities; or the encouraged, suggested orforced consumption of alcohol or other disorienting substances.Any such activity is wrongful and in violation of the Sorority’s policy regardless ofwhether any person or persons involved in the conduct believe that the participants inthe activities are doing so by consent.The Sorority also adopts and incorporates herein the hazing policies established by theNational Pan Hellenic Council.PENALTIESAny person who engages [or participates] in, encourages, aids, or assists in hazing is inviolation of the Sorority’s policy against hazing and subject to:1. DISCIPLINARY ACTION by the Sorority, including permanent expulsion and lossof privileges;2. DISCIPLINARY ACTION by the College/University in accordance with applicablecampus and student rules of conduct;3. CRIMINAL PROSECUTION in accordance with local, state and federal criminalcodes and statutes;4. CIVIL CLAIMS filed by this Sorority against any person who violates theSorority’s policy and thereby causes the Sorority to be demeaned in the eyes ofthe public or made the subject of litigation involving an alleged violation of thispolicy.16SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

WAIVER OF CLAIMS AGAINST THE SORORITYAll persons executing this Form and any person who participates in an incident orincidents of hazing, including any person subjected to, or claiming injuries as aresult of alleged hazing, releases and agrees not to hold the Sorority, its Directors,Officers or Staff liable or responsible for any and all claims, suits, losses, costs,expenses or damages (including attorneys’ fees or punitive damages) that arise outof or otherwise relate in any way to such incident or incidents.OTHER PERSONAL ACKNOWLEDGEMENTS AND COMMITMENTSIN ALL CIRCUMSTANCES: The individual conduct and the activities of ourmembers and membership must be lawful, dignified and in complete accordancewith the Sorority’s policy on hazing.IN ALL CIRCUMSTANCES: There are no “above” or “underground” activitiesrequired to gain or retain admission into this Sorority.IN ALL CIRCUMSTANCES: Any PERSON who might ever be requested to violatethe Sorority’s policy against hazing, or who might otherwise be asked to engage indemeaning or dangerous conduct, agrees to REFUSE such a request andimmediately report such conduct to the Sorority, so that the Sorority can takeappropriate action.THE UNDERSIGNED has read the Sorority’s Policy stated above, understands itsmeaning in regard to her own responsibility to prevent hazing or dangerous conduct,(the waiver of claims against the Sorority), and agrees to act in complete accordancewith this policy.Chapter: _____________________________________________________Date: _____________________________________________________________________________________________________________________Printed Name of Applicant_____________________________________________________________Signature of Applicant_____________________________________________________________Printed Name of Witness_____________________________________________________________Signature of Witness (Undergrad Advisor or Alumnae Membership Chair)17SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

Sigma Gamma RhoEVENT PLANNING GUIDELINESSpecial events are expected and anticipated in our chapters. However, it isimportant that these special events be well-planned and safe. SigmaGamma Rho Sorority, Inc. and its Board of Directors encourages bothGraduate and Undergraduate chapters to complete the attached EventPlanning Checklist whenever an event is planned. Please note that ifalcohol is to be served (graduate chapters only) or if additionalorganizations or businesses need to be insured as part of your event, youmust complete the Event Planning Checklist and submit it and allsupporting documents to the National Headquarters at least two weeksprior to the event.If Sigma Gamma Rho has been asked for proof of insurance, such proofwill not be issued until this Checklist has been submitted, nor will AdditionalInsured documents be issued.Fax, Mail or Email the completed forms to:Sigma Gamma Rho Sorority, Inc.Attn: Rachel Morris1000 Southhill Drive, Suite 200Cary, NC 27513-8630fax: (919)573-9119email: administrativeassistant@sgrho1922.org.18SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

I. What is the form of transportation to the event? _____________If the event is out-of-town, explain the plan to ensure that all chapter members utilize thechartered transportation________J. Activities1. Describe the event and the activities that are planned for the event.2. Is this an athletic event? Yes No________________________________________If yes, all participants must complete the Athletic Participation Waiver (found at the end of thischecklist and in the Willis HRH Insurance Manual.)II.RISK MANAGEMENTA. Guest List1. Who is responsible for preparation of the guest list? (The guest list should include membersattending, their guests and all attendees’ birthdates.)________________2. Explain how those in attendance will sign in and out of the event. (Once an individual has leftthe event, that individual may not return.)B. Identification1. Who is responsible for checking legal identification?________________2. Who will be matching identifications to the guest list?C. Security1. Will there be security guards present? Yes NoIf so, how many guards will be present, and what are their responsibilities?20SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

8) RefreshmentsPlease note:No alcoholic beverages may be served at an undergraduate eventNo alcoholic beverages may be removed from the event area by members or guestsThe vendor must stop serving alcohol at least ½ hour prior to the conclusion of theeventWhat type(s) and quantity of food and non-alcoholic beverages will be provided?III.SITE INSPECTIONA. Pre-event condition of the property:Prior to the event, both parties have verified the condition of the property.B. Reminders for post-event condition of the property:1. Walk through with a manager at the conclusion of the event.2. Sign off on the condition of the property.YesNoIV.EMERGENCY CONTACTSHave the following phone numbers available in case of an emergency:1. Emergency personnel2. Chapter President3. Chapter Advisor4. Greek Advisor5. Headquarters (919) 678-9720V. CHAPTER EVENT SIGNATURE APPROVALA. This event was planned by:NameOfficeSignature Phone DateIf applicable, this executive board officer oversaw the planning of the event:NameOfficeSignature Phone DateB. Sigma Gamma Rho Sorority, Inc. Headquarters ApprovalNameOfficeSignature Phone Date22SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

SIGMA GAMMA RHOADDITIONAL INSURED REQUEST FORMChapter Name: ______________________________________________________________Your Name: _________________________________________________________________Your Address: _______________________________________________________________City, State, Zip: ______________________________________________________________Phone: _____________________________________________________________________E-Mail Address: ______________________________________________________________FAX (if available): ____________________________________________________________Additional Insured’s Name: _____________________________________________________Address: ___________________________________________________________________City, State, Zip: ______________________________________________________________Phone: _____________________________________________________________________E-Mail Address: ______________________________________________________________Date and Time of Event: ________________________________________________________Description:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Fax, Mail or Email the completed forms to:Sigma Gamma Rho Sorority, Inc.Attn: Rachel Morris1000 Southhill Drive, Suite 200Cary, NC 27513-8630fax: (919)573-9119email: administrativeassistant@sgrho1922.org.23SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

SIGMA GAMMA RHOATHLETIC EVENT PARTICIPATION WAIVERI, __________________________________, a registered participant in an activity sponsored by_________________ Chapter of Sigma Gamma Rho, understand and agree that I amparticipating in this event on my own free will and accord and that neither _________________chapter, nor Sigma Gamma Rho Sorority, Inc., nor its insurer(s) will share in or acceptresponsibility for any liability for bodily injury, property damage, medical expense or other lossthat may arise from my participation in this event.I further understand and agree, and have no expectation that __________________ chapter, orSigma Gamma Rho Sorority, Inc. will provide any form of security or other measure ofsafeguarding for this event, as there is no reasonable expectation that such will be necessary.I further understand and agree that this event is considered a “no-fault” event by me, as well as___________________ chapter, and Sigma Gamma Rho Sorority, Inc. and in the even of bodilyinjury, property damage, necessity of medical expenses or other loss, I agree to incur my ownexpenses without input or participation from ____________________ chapter, or SigmaGamma Rho Sorority, Inc., or its insurer(s)._________________________Guest/Participant________________________Chapter Representative_________________________Witness________________________Witness_________________________Date________________________DateThis form should be only used for athletic events and completed for all participants.Chapters should keep the waiver forms for possible liability issues and record keepingpurposes for five (5) years.24SIGMA GAMMA RHO SORORITYINSURANCE AND CLAIM MANUAL

MAPP claim formsFraternityMember Accident Protection ProgramFor Member Coverage Information &Initial Claim ReportingCALL 800-736-4327 EXT. 208HSR Plaza II4100 Medical ParkwayCarrollton, Texas 75007Phone: (972) 512-5600 Fax: (972) 512-5838For Claim QuestionsToll Free: (866) 523-3452E-Mail : fraternity@hsri.comPART I – INJURED MEMBER REPORT1. NAME OF (INTER)NATIONAL FRATERNITYSigma Gamma Rho- 4102AH274447-33. NAME OF INJURED PERSON 4. SOCIAL SECURITY NUMBER- -2. COLLEGE OR UNIVERSITY WHERE CHAPTER IS LOCATED7. ADDRESS OF INJURED PERSON, BEST CONTACT PHONE NUMBER (INCLUDE AREA CODE)5. E-Mail 6. BIRTHDAY___ / ___ / ___8. PARENTS’ NAME, ADDRESS AND BEST CONTACT PHONE NUMBER (INCLUDE AREA CODE)9. DATE AND TIME OF ACCIDENT 10. PLACE WHERE ACCIDENT OCCURRED13. NATURE OF INJURY (INDICATE PART OF BODY INJURED - SUCH AS BROKEN ARM, SPRAINED ANKLE, ETC.)14. DESCRIBE HOW ACCIDENT OCCURRED - GIVE ALL POSSIBLE DETAILS - MUST BE A BODILY INJURY DUE TO ACCIDENT15. DID ACCIDENT OCCUR (CIRCLE YES OR NO) FOR EACH OF THE FOLLOWING:During a fraternity organized activity or on fraternity property?YES NO (See question 16)While on the job (if applicable)?YES NODuring intercollegiate/scholastic athletic practice or competition?YES NODuring a university or college sponsored activity?YES NOAre you currently enrolled in the university or college where your chapter is located?YES NO16. IF THE INJURY OCCURRED DURING A FRATERNITY SPONSORED EVENT, PLEASE PROVIDE THE NAME AND LOCATION OF THE EVENT:PART II – OTHER INSURANCE STATEMENTDo you/spouse/parent have medical/health care or is the Claimant enrolled as an individual, employee or dependent member of a Health MaintenanceOrganization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through your employer or other sourceon you or does your son/daughter have health care coverage as a dependent from your previous marriage as mandated in a divorce decree? YESNOIf Yes: Name of insurance company ________________________________________________________ Policy #____________________________Name of insurance company ________________________________________________________ Policy #___________________________IF OTHER INSURANCE OR HEALTH CARE PLANS EXIST, PLEASE SUBMIT COPIES of their EXPLANATION OF BENEFITSalong with your claim.IF NO OTHER INSURANCE or HEALTH PLAN EXISTS, PLEASE READ & SIGN BELOW.I agree that should it be determined at a later date there is insurance (or similar), to reimburse HEALTH SPECIAL RISK, INC., or the insurancecompany to the extent of any amount collectible.SIGNATURE OF PARTICIPANT OR PARENT WITNESS DATEAUTHORIZATION TO PAY BENEFITS TO PROVIDERI authorize medical payments to physician or supplier for services described on any attached statements enclosed.SIGNATURE _______________________________________________________ DATE _____________________I hereby authorize any insurance company, hospital, physician or other person who has attended or examined the claimant to disclose when requested to doso, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medicalrecords. A photo static copy of this authorization shall be considered as effective and valid as the original.SIGNATURE _______________________________________________________ DATE _____________________TO BE COMPLETED BY PROGRAM ADMINISTRATORSIGNATURE OF PROGRAM REPRESENTATIVE TITLE DATE25

FRAUD STATEMENTSGENERAL: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance orstatement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act.ALASKA, ARKANSAS, IDAHO, INDIANA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company filesa claim containing false, incomplete, or misleading information is guilty of a felony.ARIZONA: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a falseor fraudulent claim for payment of a loss is subject to criminal and civil penalties.CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false orfraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposeof defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Anyinsurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to apolicyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or awardpayable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing anyfalse, incomplete or misleading information is guilty of a felony.DISTRICT OF COLUMBIA RESIDENTS: WARNING It is a crime to provide false or misleading information to an insurer for the purpose ofdefrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits iffalse information materially related to a claim was provided by the applicant.FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an applicationcontaining any false, incomplete, or misleading information is guilty of a felony of the third degree.KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claimcontaining any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commitsa fraudulent insurance act, which is a crime.MARYLAND: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application forinsurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerningany fact material thereto, commits a fraudulent insurance act.MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containingany false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal andcivil penalties.NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents falseinformation in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.26

NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance orstatement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any factmaterial thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousanddollars and the stated value of the claim for each such violation.OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files aclaim containing a false or deceptive statement is guilty of insurance fraud.OREGON: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insuranceor statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning anymaterial fact, may have committed a fraudulent insurance act.PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application forinsurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning anyfact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties.TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose ofdefrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.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 finesand confinement in state prison.VIRGINIA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application orfiles a claim containing a false or deceptive statement may have violated state law.27

DEFINITIONSCertificate of Liability Insurance: This is a certificate issued by the insurance company detailing the particulars of theinsurance coverage in place for all chapters and regions under the general liability policy. This certificate may be used todocument the existence of coverages for chapters and regions. This document is not sufficient when a third party requests acertificate where they are named as an additional insured.Certificate of Liability Insurance for an Additional Insured: This is a certificate issued by the insurance company detailingthe particulars of the insurance coverage in place for all chapters and regions under the general liability policy. Thisdocument specifically identifies a third party as being expressly covered under the general liability policy for a specifiedperiod of time (i.e. an additional insured). This form of insurance certificate is often requested by facilities where chapters orregions are planning to hold events.Special Event: Events other than those where Sorority business is the primary purpose of the meeting are consideredSpecial Events. In general, all special events are covered under the general liability policy. However, there are specificevents that have been deemed to be high risk. When these sorts of events are planned by chapters, approval from theNational Headquarters must be sought 30 days prior to the event date (See special events section in the manual on page 7.).General Liability Insurance: Coverage that pertains, for the most part, to claims arising out of the insured’s liability forinjuries or damage caused by ownership of property, manufacturing operations, contracting operations, sale or distribution ofproducts, and the operation of machinery, as well as professional services.Director’s & Officer’s Liability Insurance: Offers directors and officers protection from personal liability and financial lossarising out of wrongful acts committed or allegedly committed in their capacity as officers and/or directors.Aggregate Limit: A limit in an insurance policy stipulating the most it will pay for all covered losses sustained during aspecified period of time, usually one year. Aggregate limits are commonly included in liability policies and apply per chapterlocation.Occurrence: An accident, including continuous or repeated exposure to substantially the same general, harmful conditions.Claim: An incident where the injured party is making a demand for compensation under the terms of an insurance contract.Incident: An occurrence involving bodily injury to a member or guest that does not result in a formal claim. All incidents mustbe reported when discovered due to possibility of them becoming a claimBodily Injury: Injury to the body, sickness or disease sustained by a person, including death resulting from any of these atany timeProperty Damage: Physical injury to tangible property, including all resulting loss of use of that property. All such loss of useshall be deemed to occur at the time of the physical injury that caused it; or Loss of use of tangible property that is notphysically injured. All such loss of use shall be deemed to occur at the time of the “occurrence” that caused it.29