OFFENSE-DEFENSE FOOTBALL LEAGUE 2015 – 2016 INSURANCE APPLICATION 309 Bush Drive, Myrtle Beach, SC 29579 | 843-903-1888 General Liability Limits Each occurrence Limit Abuse Coverage Deductible $ 1,000,000 (25,000 med) or 2,000,000 (100,000 med) $ 1,000,000 $ 0.00 General Aggregate Limit Hired/Non-Owned auto $5,000,000 $1,000,000 Excess Accident Medical Limits Accident Medical Expense Benefit AD & D $ $ 25,000 or 100,000 Deductible (Per Claim) 5,000 $250 Name of League: Contact or Coach: Address: City: State: Zip: Cell Phone: Fax Number: Email: Work Phone: Football Accident Medical Accident Medical $25,000 OR $100,000 Cheer Flag ________ X $224 OR _______ X $260 __________ X $0 12 years and Under - # of Teams ________ X $345 OR _______ X $400 __________ X $0 13 to 15 years old - # of Teams ________ X $445 OR _______ X $475 __________ X $0 16 to 19 years old - # of Teams ________ X $475 OR _______ X $520 __________ X $0 MEMBERS of the ODFL will receive special pricing on the insurance rates posted above. There is a 3% credit card processing fee for any payment made by credit card. ADDITIONAL INSURED CERTIFICATE(S) If you need a certificate of insurance for the city, municipality, school district etc. please complete the section below. 1) Name: Address: City: State: Zip Code: State: Zip Code: 2) Name: Address: City: (If additional names are needed, provide on a separate piece of paper.) I understand and agree that if this application is accepted by the Company, coverage will begin on the date of acceptance, subject to the payment of the required premium. Any person who, with intent to defraud or knowing that he/she is facilitating against an insurer, submits application or files claims containing a false or deceptive statement is guilty of insurance fraud. By checking the box to the left, I certify that, I / The League have conducted background checks on all staff, coaches, volunteers or other personnel having any involvement with my team and/or league. Signature: ___________________________________________________ Date: __________________________________________ Complete the application in its entirety to avoid delays. Make checks payable to Offense-Defense and mail to: Offense – Defense, 309 Bush Drive, Myrtle Beach, SC 29579 ALL ROSTERS MUST BE SUBMITTED BY SEPTEMBER 15TH, 2015 or policy is subject to cancellation