Purchase BPA Team Preferred Membership Benefits
Rates Effective: 1/1/16 – 1/1/17

Instructions:

Please enter the information below to complete the application for the Team Preferred Membership Benefits Program. 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 teams:
(4 teams or more)

Age Range

Number

X Rate

= Total Premium

8 and under

10 and under

12 and under

14 and under

16 and under

18 and under

20 and under

Adult

Total

Number of teams:
(3 teams or less)

Age Range

Number

X Rate

= Total Premium

8 and under

10 and under

12 and under

14 and under

16 and under

18 and under

20 and under

Adult

Total

= Total Premium Due

Requested Effective Date :

Organization Name:

Mailing Address:

Email:

Phone:

Fax:

Contact Name:

Contact Address:

City:

State:

Zip:

Phone:

Fax:

Insured Teams:

If you don’t have a BPA Sanction Number, go to:

http://www.playbpa.com/modules.php?name=Team&file=create_new_team

If you don’t have a BPA Sanction Number, go to:

http://www.playbpa.com/modules.php?name=Team&file=create_new_team

Team Name:

BPA Sanction Number:

Team Name:

BPA Sanction Number:

Team Name:

BPA Sanction Number:

Team Name:

BPA Sanction Number:

To add more enter one team and BPA sanction number pair per line.

Additional Insureds:

(i.e.: field owners, municipalities, schools, parks, rec center, etc)

Name:

Address:

City:

State:

Zip:

Name:

Address:

City:

State:

Zip:

To add more enter below.

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 BPA Team Preferred Membership BenefitsRates Effective: 1/1/16 – 1/1/17

Purchase BPA Team Preferred Membership Benefits
Rates Effective: 1/1/16 – 1/1/17