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2010 NASF Officials Insurance Form

Fields indicated with a *are mandatory.
* Contact Name: * Email:
* Day Phone: Evening Phone:
* Address: * City:
* State: * Zip:

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Please Use one Form to Sign up multiple Officials in league.

Put Official/Umpires Name, email!)
Enter one Official per line and multiple Sports Officiated per line

Official's Name 1:

Official's Name 2:

 

 

Official's Email 1:

Official's Email 2:

 

 

Official's Name 3:

Official's Name 4:

 

 

Official's Email 3:

Official's Email 4:

 

 

Official's Name 5:

Official's Name 6:

 

 

Official's Email 5:

Official's Email 6:

 

 

Official's Name 7:

Official's Name 8:

 

 

Official's Email 7:

Official's Email 8:

 

 

Official's Name 9:

Official's Name 10:

 

 

Official's Email 9:

Official's Email 10:

 

 
* Are you obligated to name any organization as an Additional Insured. If so, please complete:
Additional Insured Name Complete Address Relationship to You

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# of Officials: Times

Rates Per Official:

 $ + $10 Administration Fee = Total Cost: $
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Payment by: Check, money order or credit card must be received by the insurance Co. before certificates can be issued!

Make Check payable to: For Credit Card Information:

Special Markets Ins. Consultants
2615 Post Road Stevens Point, WI 54481
nasf@specialmarkets.com

Special Markets Ins. Consultants
2615 Post Road Stevens Point, WI 54481
Telephone:800 727 7642 ext 23 FAX:715 344 6126