UNITED STATES OF AMERICA
CRICKET ASSOCIATION CLUB LIABILITY AND ACCIDENT INSURANCE PROGRAM

 

Complete the below enrollment form in full. Coverage is effective 1/1/07 to 1/1/08. Payment of $125.00 is required at time of enrollment through VISA or MasterCard. Your liability certificate policy, applicable claim filing information and any applicable additional insureds will be e-mailed back to the indicated e-mail address.

* = Required Information

Name of Organization *
Address of Organization *
Are you a... Club    or a    League?
City/State/Zip *
Phone Number
E-Mail Address *

Requested Effective Date of Coverage
(Coverage is Annual)

 *

Would you like to include hired and non-owned automobile liability coverage? An additional premium of $1250.00 is required.

 Yes   No
Would you like to add an additional $1,000,000.00 of liability coverage? An additional premium of $1,250.00 is required. Yes   No
Would you like to add an additional $2,000,000.00 of liability coverage? An additional premium of $2,500.00 is required.
 Yes   No

Would you like to add the optional pre-existing injury benefit? An additional premium of $120.00 is required.

 Yes   No

Would you like to add the optional sickness benefit? An additional premium of $195.00 is required.

 Yes   No

Would you like to include sexual abuse and molestation coverage? An additional premium of $1,250.00 is required.

 Yes   No


NUMBER OF CLUBS IN LEAGUE X $125.00 = $ PREMIUM DUE.

Please indicate below the entities requiring certificates of insurance. The full name and address is needed to add entities as an additional insured.

Certificate Holder #1

Name
Address
City/State/Zip
Special Instructions

Certificate Holder #2

Name
Address
City/State/Zip
Special Instructions

Payment Information

We accept Visa, Mastercard, and American Express

Name on Credit Card
Card Billing Address
Card Billing City/State/Zip
Credit Card Type
Credit Card Number
Expiration Date MM/YY

I certify the statements given on this enrollment form are true and correct. I understand that this description of coverage illustrates the highlights of this program, but is not a contract. Some exclusions and coverages may be modified to meet individual state requirements.

When you are ready to verify your enrollment form, click proceed below.

Questions and Comments regarding this insurance program may be directed to
rocorona@wescom.org.

Wescom Insurance Services, Inc.
USACA Agent of Record
10222 Lakewood Blvd.
Downey, CA. 90241
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