Contact Name:

Team/League/Association Name:	Contact Address:

Contact Phone Number:	Contact Email:

Note: The requested endorsement will be emailed to contact.

Please check one of the following and sign below.

We have purchased event coverage through USA Lacrosse and RPS Bollinger under the following.

☐We have confirmed that 100% of our players and coaches are members of USA Lacrosse, and we have already printed the certificate at www.RPSBollinger.com on	(date).

OR

☐We have purchased event coverage through USA Lacrosse and RPS Bollinger under the following.

Name:	Date:

Name of entity: List the below the full name and address of organization/entity to be added as well as the specific language requested. One per endorsement.

There is a $50 charge for each additional insured special wording endorsement request per policy term (1/1 to 12/31).
This charge cannot be prorated.

Please allow two to three business days to process the endorsement.

Payment Information:

If paying by check, please submit payment to Bollinger, Inc.,
PO Box 1322, Morristown, NJ 07960.

Questions?

Call: RPS Bollinger at 800.446.5311, then press 5 for Lacrosse

Email: Lacrosse@RPSins.com

Fax: 973.921.8474, Attention: Lacrosse Representative