Fill Out The Form Below and we will respond to your questions

• 1.

• *First Name
  

  *Last Name
  

• *Phone
  

  *E-mail
  

• 2.

• Basketball Program Name
  

• 3.

• Street Address
  

• City
  

  State
  

  ZIP Code
  

• 4.

• Effective Date of Coverage
  

• 5.

• Plan of Benefits:

  Maximum Medical Expense Benefit- Per person: $25,000
  Accidental Death & Dismemberment Benefit Principal Sum: $10,000
  Deductible amount: $100/injury
  Liability Coverage: General Aggregate: $2,000,000.00
  Liability Coverage: Each Occurrence: $1,000,000.00

• Optional Non-Owned Automobile Liability
  -- Select Option -- Yes No

• 6.

• Number of Players
  

  Additional Insured
  

• Total premium Due Company = $4.30 X # of players
  
  Minimum Policy Premium = $465

  I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or on the date requested in Question [4] above, whichever is later, subject to the payment of the required premium, and (b) no contribution to the premium will be made by an insured person. Premium computation is subject to audit. It is also understood that no agent is authorized to accept risk or pass on insurability.
  
  Any person, who, with intent to defraud or knowing that is facilitating a fraud against an insurer, submits application or files claims containing false or deceptive statement may be guilty of insurance fraud.
  I Agree and Understand

• Policyholder Signature
  

  Title of Group Official
  

• Questions/Comments (optional)