INDEPENDENT SOFTBALL ASSOCIATION 2010

YOUTH & ADULT

1-800-447-6797

TOURNAMENT NAME__________________________________________________

TOURNAMENT DATES__________________ TO ____________________________

TOURNAMENT DIRECTOR______________________________________________

ADDRESS______________________________________________________________

CITY _______________________________STATE________ ZIP_________________

DAYTIME PHONE(_________)____________________________________________

EMAIL_________________________________________________________________

TYPE OF TOURNAMENT (CIRCLE ONE): SOFTBALL BASEBALL

COMPLETE ONLY IF FIELD OWNER REQUESTS ADDITIONAL INSURED STATUS

NAME OF FIELD OWNER_____________________________________________________

ADDRESS____________________________________________________________________

CITY ____________________________STATE________________ZIP__________________

PREMIUM CALCULATION:

# OF YOUTH TEAMS _______ X $7 = ________

# OF ADULT TEAMS _________ X $16 = ________

MAKE CHECK PAYABLE TO: CHAPPELL INSURANCE AGENCY &

MAIL TO: 25807-A COX ROAD, PETERSBURG, VA 23803

OR CALL 1-800-447-6797 TO PURCHASE WITH CREDIT CARD

____________________________________________________________

Certificates will be emailed. If email not available then faxed

EMAIL ADDRESS:__________________________________________________________

FAX #:_____________________________________________________________________

ALL RATES INCLUDE AN ADMINISTRATION AND MEMBERSHIP FEE.