Universal Sports Insurance
Responsible Person's Name:_______________________________________________________
Address:______________________________________________________________________
City:_________________________________________State:__________Zip:_______________
E-Mail Address ________________________________________________________________
Home Phone:__________________________________________________________________
I certify that all information listed above is true and correct.
Signature:______________________________________________Date:___________________
. (This application must be signed)
Rates
Combined Accident Medical Expense/Liability
Coverage:
8 & under $75.00 per team
10 & under $100.00 per team
12 & under $125.00 per team
14 & under $140.00 per team
16 & under $150.00 per team
18 & under $180.00 per team
Mail completed form, and your annual premium to:
Make Checks payable to:
Universal Sports Insurance
3330 Ernest Pridgen Rd.
Wray Ga. 31798