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DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />AGENCY CUSTOMER ID: <br />LOC #: <br />ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br />AGENCY <br />American Specialty Insurance & Risk Services, Inc. <br />POLICY NUMBER <br />SBCGL0408100 <br />CARRIER <br />Arch Insurance Company <br />ADDITIONAL REMARKS <br />NAMED INSURED <br />Disabled Sports USA, Inc. <br />451 Hungerford Drive, Suite 608 <br />NAIC CODE Rockville, MD 20850 <br />11150 EFFECTIVE DATE: 12/01/2017 <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE -Certificate #1001595594 <br />- The General Liability policy includes Form CG 2116 Exclusion - Designated Professional Services with the following professional services excluded: Providing <br />or failure to provide medical professional services. <br />- The General Liability policy includes Form CG 2144 Limitation of Coverage to Designated Premises or Project, with the following Scheduled Project/Premises <br />limitation: Events, activities, and business operations related to Disabled Sports USA <br />- The General Liability policy includes Form 00 SGL0118 00 Construction Operations Limited Coverage, with the following Construction Operations scheduled: <br />NONE <br />- Coverage available under policy # SRPO- 50219 -203 is on file with the policyholder. Excess Accident Medical for Class 1 & 2 - $25,000 with a $250 deductible <br />per injury per covered accident. Accidental Death & Dismemberment is $10,000 per person per accident. Class 3 & 4 - $100,000 with a $250 deductible per <br />injury per covered accident. Accidental Death & Dismemberment is $10,000 per person per accident. <br />- With regards to the Excess Accident Medical Coverage, Class 1 & 3 is all registered /approved participants and volunteers of the Participating Organization <br />and its Chapters with respect to sponsored and approved activities including direct travel to and from the activity and home, not including overnight trips. <br />- With regards to the Excess Accident Medical Coverage, Class 2 & 4 is all registered /approved participants and volunteers of the Participating Organization <br />and its Chapters with respect to sponsored and approved overnight trips including direct travel to and from the activity and home. <br />- The Certificate Holder is only an Additional Insured with respect to liability caused by the negligence of the Named Insured as per Form 00 SGL0026 00 <br />Additional Insured - Certificate Holders, but only with respect to BRIDGE II SPORTS ADAPTED PROGRAMMING from August 13, 2018 through November 30, <br />2018. <br />ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />