League Application for Insurance - Offense

OFFENSE-DEFENSE FOOTBALL LEAGUE
2015 – 2016 INSURANCE APPLICATION
309 Bush Drive, Myrtle Beach, SC 29579 | 843-903-1888
General Liability Limits
Each occurrence Limit
Abuse Coverage
Deductible
$ 1,000,000 (25,000 med) or 2,000,000 (100,000 med)
$ 1,000,000
$ 0.00
General Aggregate Limit
Hired/Non-Owned auto
$5,000,000
$1,000,000
Excess Accident Medical Limits
Accident Medical Expense Benefit
AD & D
$
$
25,000 or 100,000 Deductible (Per Claim)
5,000
$250
Name of League:
Contact or Coach:
Address:
City:
State:
Zip:
Cell Phone:
Fax Number:
Email:
Work Phone:
Football
Accident Medical
Accident Medical
$25,000
OR
$100,000
Cheer
Flag
________ X $224 OR _______ X $260
__________ X $0
12 years and Under - # of Teams
________ X $345 OR _______ X $400
__________ X $0
13 to 15 years old - # of Teams
________ X $445 OR _______ X $475
__________ X $0
16 to 19 years old - # of Teams
________ X $475 OR _______ X $520
__________ X $0
MEMBERS of the ODFL will receive special pricing on the insurance rates posted above. There is a 3% credit card processing fee for any
payment made by credit card.
ADDITIONAL INSURED CERTIFICATE(S)
If you need a certificate of insurance for the city, municipality, school district etc. please complete the section below.
1) Name:
Address:
City:
State:
Zip Code:
State:
Zip Code:
2) Name:
Address:
City:
(If additional names are needed, provide on a separate piece of paper.)
I understand and agree that if this application is accepted by the Company, coverage will begin on the date of acceptance, subject to the
payment of the required premium. Any person who, with intent to defraud or knowing that he/she is facilitating against an insurer, submits
application or files claims containing a false or deceptive statement is guilty of insurance fraud.
By checking the box to the left, I certify that, I / The League have conducted background checks on all staff, coaches, volunteers
or other personnel having any involvement with my team and/or league.
Signature: ___________________________________________________
Date: __________________________________________
Complete the application in its entirety to avoid delays. Make checks payable to Offense-Defense and mail to:
Offense – Defense, 309 Bush Drive, Myrtle Beach, SC 29579
ALL ROSTERS MUST BE SUBMITTED BY SEPTEMBER 15TH, 2015 or policy is subject to cancellation