contact info：联系信息

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1、NATIONALHIGHSCHOOLCOACHESASSOCIATIONINSURANCEPROGRAMFORCAMPS/CLINICS/TOURNAMENTSYoumustbeacurrentmemberoftheNHSCAinordertopurchasecamp,clinic,ortournamentinsurance.Ifyouarenotacurrentmember,themembershipwillbeaddeduponsubmission.Onthedayyoureventstarts,pleasesubmitrosters(firstandla

2、stnames)totheNHSCA.Youwillbechargedaccordinglyandreceiveyourreceiptviaemail.PleaseNote:AsofJanuary1,2014,thereisa$125minimumonallinsurancerequests.Besuretosubmitrequest2businessdayspriortothestartofyoureventtoensurecoverage!Ifyouneedtocancelyourevent,pleasesendinwritingtoMattie2days

3、inadvancetoavoidtheminimumfee.Pleaseprintclearly!CONTACTINFO:NamedInsured:_________________________________________NameofCamp/Clinic/Tournament:_____________________________________________Address:__________________________________________________City:_______________________________

4、State:_______Zip:________Phone:___________________E-MailAddress:_______________________________EVENTINFO:NameofCamp/Clinic/Tournament:____________________________________________Sport:______________________________________________LocationofCamp/Clinic/Tournament:____________________

5、____________________Address:______________________________________________City:___________________State:_______Zip:___________EventStartDate:___________EventEndDate:___________ADDITIONALINSUREDINFORMATION:NameofAdditionalInsured’s:______________Address:______________________City:___

6、________________State:___Zip:______Manager/lessorsofPremises:____Ifother,explainrelationship:___________________Phone:(610)923-0900Fax:(610)923-0800Email:MPotter@nhsca.comNATIONALHIGHSCHOOLCOACHESASSOCIATIONINSURANCEPROGRAMFORCAMPS/CLINICS/TOURNAMENTSNameofAdditionalInsured’s:______

7、_________________________________________Address:________________________City:_______________State:___Zip:______Manager/lessorsofPremises:____Ifother,explainrelationship:___________________NameofAdditionalInsured’s:_______________________________________________Address:_____________

8、___________City:___