Field Permit Insurance

Injury & Liability for a Kickball Team and its Opponents' Liability on a Per Game Basis

Payment accepted ONLY through PayPal with e-check, a PayPal account or credit card.

USE THIS FORM IF......ONLY YOUR TEAM OR JUST SOME OF THE TEAMS
IN YOUR LEAGUE, GROUP OR DIVISION HAS INSURANCE.

This form is for kickball teams in groups, divisions or leagues that do not have insurance for all of their teams. The coverage is based on the number of dates issued ON your field permit so that each day you play, your Opponent(s) will also be covered by insurance regardless of whether or not your opponent is in your league or has other insurance. The field owner, your sponsors, players, coaches, passersby and spectators as well as personal property on or near the field are covered by $5 million of liability insurance with a $250 or $500 deductible, depending on your policy. Your players will ALWAYS be covered with $250,000 of injury insurance while playing on any ASA or USA kickball team throughout the nation for the entire calendar year.

Please Enter Your Team Information:

League in which your team plays:

Your Kickball Team's Name:

Captain's First Name:

Captain's Last Name:

Captain's Contact E-Mail:

If your PayPal e-mail differs from your kickball contact e-mail address, please list only the captain's primary e-mail address.

If you have any questions, contact the commissioner at CongAthleticAsc@aol.com

Please Enter Your Shipping Address (if your order requires shipping):

If your order below requires shipping, you must complete this section.

First Name:

Last Name:

Street Address 1:

Street Address 2:

City, State, and Zip:

This form is for teams in groups, divisions or leagues in which all of their teams are NOT covered by liability insurance. Your team's coverage is based on the number of games you play on your schedule or the number of days specified on your field permit. Your team fee will be based on covering each of the opponents you play as well as your team. On the second line below, select the number of days or games you will play which will determine your fee.

Quantity	ID	Description	Unit Fee	Amount
		Team Insurance Fee
Games		Schedule Insurance Fee (Based on number of games)

# of Players

			Subtotal	$
			Shipping	$
			TOTAL	$

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