Team Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Team Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your coverage ever been Cancelled of Refused? *

Yes

No

Have you had any claims in the past 4 years? *

Yes

No

Is your team Youth or Adult players? *

YOUTH (18 & Under)

ADULT (19 & Older)

Are participants required to sign a Waiver & Release of Liability?

Yes

No

If yes, are copies of the Waiver & Release of Liability kept on file?

Yes

No

Do you currently have a risk management plan?

Yes

No

The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. *

I Agree

I AUTHORIZE FRANCIS L. DEAN & ASSOCIATES TO CHARGE MY PAYMENT INFORMATION PROVIDED ON THIS FORM. *

I AGREE