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2012 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

Insurance Cost: # of Officials: Times Rates Per Official: $ = Cost: $
Annual NASF Officials Registration: # NASF Officials: Times $10.00 Per Official: = NASF Registration Cost: $

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The annual $10.00 NASF membership fee per team or official will be collected with your insurance enrollment.


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Make Check payable to: For Credit Card Information:
Special Markets Insurance Consultants
2615 Post Road
Stevens Point, WI 54481
Email: NASF@specialmarkets.com

Special Markets Insurance Consultants
2615 Post Road
Stevens Point, WI 54481
Phone: 800-727-7642 ext 311
Fax: 715-344-6126