Name of Policyholder   SOUTHERN YOUTH SPORTS ASSOCIATION

1.       TEAM NAME_________________________________________________________ TEAM AGE_______________

2.    Address: ______________________________________________________________________

                      Street                                        City                       State                                   Zip

3.    Contact Name:      __________________        Phone:  ______________             Fax: ____________

4.   E-Mail: _________________________________________________

5.   Effective Date of Coverage:________________  Termination Date of Coverage 8-10-10

6.   Covered Activity:                    CIRCLE ONE          Baseball        GIRLS FASTPITCH

7.   Plan of Benefits:   Maximum Medical Expense Benefit – Per Person:                                    $100,000                

Accidental Death & Dismemberment Benefit Principal Sum:           $10,000

Spectator Medical Expense                                                                $   5,000               

Choose Deductible Amount per Injury                                              $ 100.00

Excess Coverage

                                    Liability Coverage: General Aggregate:                                            $3,000,000

                                    Liability Coverage: Each Occurrence:                                               $1,000,000

8.         Premium Computation:

 ACCIDENT MEDICAL/LIABILITY

Sport of Insured Persons Age Bracket       Number of teams             Rate                   Premium

_________________    9-U (ages 4-9) _____________X        $67.00 =           ______

 __________________ 10-12              _____________X        $74.00 =           ______

_________________  13-15               _____________ X       $91.00=            ______

                        TOTAL PREMIUM: (subject to minimum premiums) = $______

I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or on the date requested in Question [4] above, whichever is later, subject to the payment of the required premium, and (b) no contribution to the premium will be made by an insured person.  Premium computation is subject to audit.   It is also understood that no agent is authorized to accept risks or pass on insurability.  Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits application or files claims containing false or deceptive statement may be guilty of insurance fraud.

TEAM MANAGER  Signature:  __________________________________    

Payment:ð  Check or Money Order

    ð  Credit Card # _____________________________________

Signature______________________________________________  Exp. Date _______   

3 DIGIT CODE ON BACK OF CARD  ______

Card Holder Zip Code  ______                                                                                                                     

Mail:  (1) Signed Application, (2) Copy of Quotation (if applicable) and (3) Full Premium Payment to:

SYSA  370 SOUTH LOWE AVE SUITE A BOX 114  COOKEVILLE, TN 38501       Paying with credit card you can  email to: teamsysa@aol.com