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2008 AMERICAN LEGION
BASEBALL ACCIDENT AND LIABILITY INSURANCE PLANS
Enrollment Form
PLEASE PRINT OR TYPE CLEARLY
Post Name and No. _____________________________________________________________________
(Please use Exact Legal Identity of Post)
Post Address, City, State & Zip
Name of Team (if different)
Is your team officially registered with the appropriate American Legion Baseball official? YesNo
Playing by American Legion rules?YesNo
Team Official to Whom Insurance Certificate is to be sent.
Name _________________________________________
PLEASE PRINT OR TYPE
Address __________________ State ______________ Zip ____________
Work Phone ( ) __________________ Home Phone ( ) ___________
A. AMERICAN LEGION ACCIDENT PLAN
Seasonal Coverage = $160.00 - OR - Year-Round Coverage = $235.00
You must select one of the above, then enter that amount here .............................. A. $
Accident coverage begins March 1, 2008 (or the date this enrollment form and check are eceived by
S. A. VAN DYK INSURANCE, at Oak Brook, Illinois; whichever date is later) and continues to
September 1, 2008 for Seasonal coverage; or to March 1, 2009 for Year-Round coverage.
B. AMERICAN LEGION BASEBALL LIABILITY PLAN
You must carry this Year-Round Coverage. The premium for this is ............................ B. $ 158.00
Liability coverage begins March 1, 2008 (or the date this enrollment form and check are received by S. A. VAN DYK INSURANCE, at Oak Brook, Illinois; whichever date is later) and continues to March 1, 2008.
C. LIABILITY CERTIFICATES OF INSURANCE are available. (Send name and address of additional certificate holders along with enrollment form and check.)
The first certificate of insurance will be issued at no charge. Additional certificates are available
at $10.00 each. Number of additional certificates x $10.00 ........................... C. $
Name Address
TOTAL ENCLOSED (add amounts for A & B [and C if needed]) ............................................................................ $_
Submitted by:
(Signature of Team Official) (Title)
Please Make Your Check Payable To: S. A. VAN DYK INSURANCE and MAIL TO: S. A. VAN DYK INSURANCE ADMINISTRATORS, AMERICAN LEGION BASEBALL INSURANCE PLANS, P.O. BOX 4806, OAK BROOK, ILLINOIS 60522-4806
ACCIDENT PLAN UNDERWRITTEN BY SENTRY INSURANCE A MUTUAL COMPANY* STEVENS POINT, WISCONSIN
LIABILITY PLAN UNDERWRITTEN BY K & K INSURANCE GROUP, INC. *FORT WAYNE, INDIANA
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