ASA Southern California Individual Registration Premium Calculation to Purchase Lower Accident Insurance Deductible

ASA Southern California Individual Registration
Premium Calculation to Purchase Lower Accident Insurance Deductible

Contact Name:	_______________________________________________________________________________
Address 1:	_______________________________________________________________________________
Address 2:	_______________________________________________________________________________
City:	_______________________________________________________________________________
State:	_______	Zip Code: ____________	Tel #: ___________________

Team Name: __________________________________________

League Name: __________________________________________

Deductible

	$100 Deductible = $1.00 per Player
	$0 Deductible = $3.00 per Player

Calculation:

_______________ X

_______________

= $ ______________

No. Of Players

Deductible Rate

Total Premium

Player Name	Address	City	State	Zip Code	Birth Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Please send this completed form along with your check to
Bollinger, 101 JFK Parkway, Short Hills, NJ 07078.
Use additional sheets if necessary or send us your roster via email,

If you have any questions, please contact Margaret Schubkegel at 1-800-350-8005 x8236