INSURANCE FORM

Team Name:
Team Mailing Address:
City
State
Zip Code
Contact Name:
Contact Phone

 

All submissions must be submitted with an N.B.C. Hap Dumont Roster Form.  Only those players listed on your roster are covered by your insurance policy.  If additions or deletions are necessary, please submit an amended roster. 
Make checks payable to:        NBC Hap Dumont Baseball

 

Your insurance won’t be affective until fees have been paid and received by NBC Hap Dumont Baseball. Mail Checks to:

                                                            Brad Glover

                                                            224 Poplar

                                                            Whitewater, KS 67154

                                                            316.799.1005
                       

I hereby certify that all information in this application is true and correct and that all team(s) insured are chartered with NBC Hap Dumont Baseball in 2006.

 

Signature of Team Official      ______________________________________

                                               
                                                                                                Date

 

12 and Under fees                  $85.00

13 to 15 year old fees             $105.00

 

Complete the section below to request additional insured status.  An additional fee will apply for each additional status

 

#1
Name of Insured:
Address
City
ST
Zip
Contact Phone	Include Area Code
#2
Name of Insured:
Address
City
ST
Zip
Contact Phone	Include Area Code