Kirkwood Athletic Association
Secondary Medical Insurance Coverage

Carrier: Starnet Insurance Company
Policy Number: PAIV00207482-001

Underwriter: DeWitt of Metro Saint Louis 314-336-9444

Policy Holder: Kirkwood Sports Association dba Kirkwood Athletic Asscoiation

Office Number to Report Claim: 314-822-3686  Facsimile 314-822-1823
Email: gkatinas@kwdaa.com or dennis@kwdaa.com

Coverage Information:
Eligibility - All Players, Coaches, Managers and Volunteers of the Policyholder.

Benefits:
$100,000 Maximum Medical Benefit Per Claim
$10,000 Accidental Death/Dismemberment Benefit Per Claim
$100 Deductable per Claim
Excess Coverage
Dental Benefit: Included in Maximum Benefit Per Claim
Policy Term January 1, 2008 through December 31, 2008
Benefit Period: 52 Weeks

Instructions to submit a claim:

Office must be notified within 5 days of any accident.  Office will need to know the name of the individual, date of injury, type of injury, team in which the player appears on roster, managers name of the team in which the player appears on the roster, age of the player.  In addition, we will need the parents address to send the incident forms for completion by medical personnel.

These forms along with bills must be forwarded to the carrier within 90 days following the accident.  Failure to do so may result in the claim being denied.