USSSA - United States Specialty Sports Association

United States Specialty Sports Association Insurance Program

Note: There is an additional charge included for online processing.

Age Group determined by the age of the oldest child on the team at the time of purchase.

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Team Name:

USSSA Team Registration Number:

Contact First Name:

Contact Last Name:

Contact Address:

Contact City:

Contact State:

Contact Zip Code:

Contact Phone:

Contact Email Address:

Complete items below only if field/facility owner requests additional insured status. Below there are text boxes to add up to 6 field/facility owners. If you have more then 6 field/facility owners, please email requests for additionals to usssa@epicbrokers.com. Make sure you include your team name and USSSA insurance certificate number with the additional field/facility information. You will receive this confirmation number after paying online.

Additional Insured 1

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

Additional Insured 2

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

Additional Insured 3

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

Additional Insured 4

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

Additional Insured 5

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

Additional Insured 6

Name of Field/Facility Owner:

Address:

City:

State:

Zip Code:

Contact Person:

Phone:

I hereby certify the above information is correct and the team is USSSA registered

Please complete the missing fields of the form

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