LITTLE DRIBBLERS’ BASKETBALL INSURANCE APPLICATION

NAME OF LEAGUE:

CONTACT PERSON:

LEAGUE ADDRESS:

CITY:

STATE

ZIP

DAY PHONE:

EVENING PHONE:

FAX:

EMAIL:

INSURANCE FEES FOR COMBINED SPORTS ACCIDENT AND GENERAL LIABILITY

ENTER NUMBER OF TEAMS TO BE INSURED

                                   X $40.00 PER TEAM =

TOTAL PREMIUM  FOR TEAM INSURANCE

$

If you need additional insurance certificates for your school or city, add an additional $26.25 for each additional insurance certificate.

Number of additional certificates:_____ X $26.25

Amount

$

TOTAL AMOUNT OWED:

$

AUTHORIZED SIGNATURE:

PRINTED NAME:

DATE: