Updated Wednesday April 17, 2019 by Culpeper Football Association.

Culpeper Football Association - Insurance


CFA Insurance Coordinator:  Mike Bailey

If you have any questions or concerns, please contact Mike at (571) 214-8272 or


K & K Insurance


1712 Magnavox Way P.O. Box 2338

Fort Wayne, Indiana 56801-2338

(800) 237-2917  (260) 459-5915


In the event of an injury to any CFA participant, the parents should receive a claim form either from the insurance coordinator or a designated manager (if the injury occurs during a game).  The claim form must be filled out this way.

The insurance coordinator must complete the bottom portion of the claim form.

The remainder of the form (Proof of Loss) is to be completed, and signed, by the parent/guardian/claimant.

If you have any questions regarding the filing of a claim, please contact our Claims Department at 1-800-237-2917.


Instructions for Insurance Coordinator

You must indicate the name of the team and/or league on the claim form.  This information is found the Certificate of Insurance in the upper left-hand corner, after the  D/B/A.

Please complete the bottom portion of the claim form in its entirety.


Instructions for Parents

Please be advised that this coverage is subject to a $100 deductible and is excess/secondary to any other valid and collectible coverage available to the claimant.  This means that if there is other heal and/or accident coverage available, all charges must be submitted to them first on a primary basis.  Subject to terms and conditions of this policy, coverage will apply to the amount not covered by other insurance. I you have other coverage, the other carrier payment(s) will be used to satisfy the deductible under this policy.  If you have no other coverage, we will apply the $100 deductible to the charges received until the deductible has been satisfied.

You are responsible for completing the upper portion of the claim form.  Omission of any information incurred with 104 weeks from the date of the accident will be considered.

If you have coverage under a HMO plan, but do not seek treatment from a provider within that play, your benefits under this policy may be reduced by the amount that would have been paid had the services been provided by a provider within your HMO plan.  You would also be responsible for the deductible under this plan.

Attach all itemized charges along with the explanation of benefits from any other insurance showing what has, or has not been paid.  We will then process the outstanding portion of your claim in accordance with them terms and conditions of this policy.

Verify that the insurance coordinator has completed the lower portion of the claim form in its entirety.


2019 Insurance Claim Form.pdf