Big Shots Endorsed Team and League Application 2018-2019 Big Shots Team and League Insurance Application - September 1, 2018 - August 31, 2019 Named Insured* as it should appear on the policy-legal name of the team or league Team/League Representative* Email* Mailing Address of Representative* Street Address City State / Province / Region ZIP / Postal Code Phone* Type of Organization* Single Team League (1-5 Teams) League (6+ teams) New or Add* This is the first application for the 2018-2019 season I have purchased a policy for the 2018-2019 season and need to add more teams Requested Effective Date of Policy MM slash DD slash YYYY Coverage is effective upon receipt of online enrollment and online credit card payment by Sadler. Coverage will expire on 09-01-2018, regardless of the effective date. CERTIFICATE OF INSURANCE INFORMATION How Many Certificates Does Your Organization Need?* 01234 The organization will automatically receive an Evidence of Coverage certificate. Certificate Holder 1 - Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Property Owner Sponsor Please indicate if any special wording or endorsments are required. Certificate Holder 2 Name* Address* Street Address City State / Province / Region ZIP / Postal Code Relationship Property Owner Sponsor Please indicate if any special wording or endorsments are required. Certificate Holder 3 Name* Address* Street Address City State / Province / Region ZIP / Postal Code Relationship Property Owner Sponsor Please indicate if any special wording or endorsments are required. Certificate Holder 4 Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Property Owner Sponsor Please indicate if any special wording or endorsments are required. PREMIUM The following represents premium for policies with an effective date of 09/01/2018 through 05/31/2019. Policies with an effective date of 06/01/2019 or later will receive a pro-rate premium, as the policy will expire on 09/01/2019. Number of Teams to Be Purchased On This Application (1-5 teams) Quantity* Price: $104.37 Quantity Number of Teams to Be Purchased On This Application (6+ teams) Quantity* Price: $94.15 Quantity Total Premium Due $0.00 Please list team name(s)* How would you like to pay for this policy today?* Credit Card (recommended) - An email will be sent to you with a credit card link within 48 business hours. Check via email - please email a completed copy of a check made payable to Sadler & Company to sport3@sadlersports.com. Do not mail the check. Check via fax - please fax a completed copy of a check made payable to Sadler & Company to 803-256-4017. Do not mail the check. Check via mail - please mail a check Payable to Sadler & Company to PO Box 5866, Columbia SC 29250 The coverage will be effective when both the application and the premium is received, whichever date is later. All certificates will be emailed. Warranty This is a Master Policy. The policy has an effective date of September 1, 2018 to September 1, 2019. Please check below that you understand and agree with the following:* Premiums are 100% fully earned and there is No Refund of premium if the policy is cancelled mid-term. Regardless of the effective date, the policy will expire 09/01/2019. I am aware that 100% of the teams within this organization must be accounted for on this application. By completing this application, I certify that the information listed above is correct and complete. Risk Purchasing Group: The completion of this enrollment form confirms our desire to obtain General Liability insurance through the ERS Risk Purchasing Group Association, Inc. domiciled in IL.
