Purchase NSA Camp and Clinic Insurance
Rates Effective: 1/1/22 - 1/1/23

Instructions:
Please enter the information below to complete the application for the Camps and Clinic Insurance Plans. Once you have entered the required information click the button below 'Continue to Payment' and you will be brought to the payment gateway.

All highlighted fields are required to continue.

Please Allow 24 - 48 hours for processing

Number of Participants *

X Number of Days *

Rate ($1.85 per participant per day)

= Total Premium Due

Start date of clinic/camp *

End date of clinic/camp *

Camp/Clinic Name: *

Camp/Clinic Coach *

Mailing Address: *

City:*

State:*

Zip: *

Email: *

Phone: *

Fax:

Camp/Clinic Facility Name: *

Camp/Clinic Facility Address: *

City:*

State:*

Zip: *

Phone: *

Fax:

Certificate should be:* Faxed Emailed

Email or Fax Number: *

To the attention of: *

Please check the box to receive our monthly newsletter.

Premium is fully earned on the effective date of coverage. No pro-rata refunds will be made. Membership includes insurance premiums & association fees. I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or the date requested in the application, whichever is later, subject to payment of the required premium; and (b) Premium computation is subject to audit. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Please check the box to verify and agree that the information provided herein is true and complete.
I Agree

Purchase NSA Camp and Clinic InsuranceRates Effective: 1/1/22 - 1/1/23

Purchase NSA Camp and Clinic Insurance
Rates Effective: 1/1/22 - 1/1/23