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2010 USSSA TEAM INSURANCE ENROLLMENT FORM (AVAILABLE TO USSSA REGISTERED TEAMS ONLY) Team or League Name _______________________________________________Team Reg. #_______________________________(LEAGUES MUST SUBMIT NAMES OF ALL TEAMS & REGISTRATION NUMBERS) Address ___________________________________________________________________________________________________City __________________________________________________ St __________________________ Zip ____________________ Contact Person ____________________________________________ Title _____________________________________________ Phone ( _____________ ) ____________________________________________________________________________________ I hereby certify that all information in this enrollment form is true and correct, and that all team(s) insured are registered with the USSSA in 2010. Team/League Official’s Signature__________________________________________ Title _________________________________ BASEBALL Complete only if field owner requests additional insured status. (For multiple fieldowners, attach a separate sheet.) Name of Field Owner _______________________________________________________________________________________ Address _________________________________________________________________________________________________ City ________________________________________________ St __________________________ Zip ____________________ Contact Person ________________________________________________ Title _______________________________________ Phone ( ___________ ) ________________________________ E-Mail ______________________________________________ Question call Tony Schultz 757-672-8479
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