2010 NASF TEAM Insurance Enrollment Form

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2010 NASF TEAM Insurance Enrollment Form

"Please complete this form and submit along with payment"

Fields indicated with a *are mandatory.

* Contact Name:		* Email:
* Home Phone:		Evening Phone:
* Address:		* City:
* State:		* Zip:
* League Name:		Indicate Sport:
* Indicate Age Group:		Other Sport:


Please Use one Form to Sign up multiple teams in Tournament.
*Put Team Names, Managers Name, Managers Email (Use Comment Block Below if Needed!)*
Team Name 1:		Manager Name 1:		Manager Email 1:
Team Name 2:		Manager Name 2:		Manager Email 2:
Team Name 3:		Manager Name 3:		Manager Email 3:
Team Name 4:		Manager Name 4:		Manager Email 4:
Team Name 5:		Manager Name 5:		Manager Email 5:
Team Name 6:		Manager Name 6:		Manager Email 6:
Team Name 7:		Manager Name 7:		Manager Email 7:
Team Name 8:		Manager Name 8:		Manager Email 8:
Team Name 9:		Manager Name 9:		Manager Email 9:
Team Name 10:		Manager Name 10:		Manager Email 10:
Team Name 11:		Manager Name 11:		Manager Email 11:
Team Name 12:		Manager Name 12:		Manager Email 12:
Team Name 13:		Manager Name 13:		Manager Email 13:
Team Name 14:		Manager Name 14:		Manager Email 14:
Team Name 15:		Manager Name 15:		Manager Email 15:
Team Name 16:		Manager Name 16:		Manager Email 16:

* Comments

* Additional Insured Names, and Addresses
Additional Insured Name 1:		Additional Insured Address 1:		City, State, Zipcode:
Additional Insured Name 2:		Additional Insured Address 2:		City, State, Zipcode 2:
Additional Insured Name 3:		Additional Insured Address 3:		City, State, Zipcode 3:
Additional Insured Name 4:		Additional Insured Address 4:		City, State, Zipcode 4:
Additional Insured Name 5:		Additional Insured Address 5:		City, State, Zipcode 5:
Additional Insured Name 6:		Additional Insured Address 6:		City, State, Zipcode 6:


# of Teams:		Times	Cost Per Team:	$ + $10 Administration Fee	=	Total Cost:	$

Make Check Payable for Additonal Fees to Special Markets Ins, Consultant 2615 Post Road Stevens Point, WI 54481 Teams outside of Pennsylvanina must pay a $10.00 membership fee per team. This check should be made payable to: NASF, 1081 Pebble Court, Mechanicsburg, PA 17050

Make Check payable to:	For Credit Card Information:
Special Markets Ins. Consultants 2615 Post Road Stevens Point, WI 54481 nasf@specialmarkets.com	2615 Post Road Stevens Point, WI 54481 Telephone:800 727 7642 ext 23 FAX:715 344 6126