CONTACTINFO：联系信息.doc

NATIONAL HIGH SCHOOL COACHES ASSOCIATIONINSURANCE PROGRAM FOR CAMPS/CLINICS/TOURNAMENTSYou must be a current member of the NHSCA in order to purchase camp, clinic, or tournament insurance. If you are not a current member, the membership will be added upon submission.On the day your event starts, please submit rosters (first and last names) to the NHSCA. You will be charged accordingly and receive your receipt via email. Please Note: As of January 1, 2014, there is a $125 minimum on all insurance requests. Be sure to submit request 2 business days prior to the start of your event to ensure coverage!If you need to cancel your event, please send in writing to Mattie 2 days in advance to avoid the minimum fee.Please print clearly!CONTACT INFO:Named Insured: _Name of Camp/Clinic/Tournament: _Address: _City: _ State: _ Zip: _Phone: _ E-Mail Address: _EVENT INFO: Name of Camp/Clinic/Tournament: _Sport: _Location of Camp/Clinic/Tournament: _Address: _City: _ State: _ Zip: _Event Start Date: _ Event End Date: _ADDITIONAL INSURED INFORMATION:Name of Additional Insureds: _ _Address: _City: _ State: _ Zip: _Manager/lessors of Premises: _ If other, explain relationship: _Name of Additional Insureds: _Address: _ City: _ State: _ Zip: _Manager/lessors of Premises: _ If other, explain relationship: _Name of Additional Insureds: _Address: _ City: _ State: _ Zip: _Manager/lessors of Premises: _ If other, explain relationship: _Credit Card Information:A credit card must be on file in order to proceed with your insurance request. If you do not wish to enter, please call the NHSCA at (610) 923-0900.Number: _ Exp. _ CVV: _Name on the Card: _*Participants include coaches, managers, staff members, team workers, officials, media personnel, VIPs, and other personnel who have been granted proper authorization to enter any restricted areas*PREMIUM CALCULATION:Number of ParticipantsRATENumber of EVENT DAYSPREMIUM$2.001$ 2.802$ 3.803$ 4.804$ 5.805$ 6.806LIMITS OF INSURANCE:COVERAGELIMITSGeneral Aggregate LimitNONEProducts Completed Operations (Aggregate)$ 1,000,000Personal And Advertising Injury$ 1,000,000Each Occurrence Limit$ 1,000,000Damage To Premises Rented to you$ 300,000Medical Expense (Premises)$ 5,000Medical Expense - Coaches Overall Maximum$ 25,000Sexual Abuse & Molestation Occurrence$ 1,000,000Sexual Abuse & Molestation Aggr