Upon completion of this questionnaire, you will be contacted by a representative from ESP Specialty Insurance. If all necessary information has been provided, you will be issued a non-binding quote for your league insurance premium.

If you have any questions about this inquiry form, please contact ESP Specialty Insurance:

Clayton March
617-993-0634
Clayton.Marsh@espspecialty.com

Joe Micciche
617-398-5562
Joe.Micciche@espspecialty.com

Chris Price
617-398-5557
Chris.Price@espspecialty.com

Name of League

League Contact

Mailing Address (street address, city, state and zip)

Phone Number

Email

Fax Number

Website

Affiliation with USA Football

League Member Affiliate Heads Up FootballNFL Flag

Are you and your staff certified by USA Football? (Required element of Heads Up Football)

YesNo

Do you follow USA Football Concussion Program protocols? (Required element of Heads Up Football)

YesNo

Do you require a completed waiver from all participants? (Required element of Heads Up Football)

YesNo

Is a parent’s signature required to register minors?

YesNo

League Details

Effective Date of Coverage (12 month policies)

Tackle - If not applicable enter "0"

Number of Tackle Teams

Number of Rookie Tackle Teams

Tackle/Cheer participants 9 and under

Tackle/Cheer participants 12 - 10

Tackle/Cheer participants 15-13

Flag - If not applicable enter "0"

Number of flag teams

Flag Participants 9 and under

Flag participants 12 - 10

Flag participants 15-13

7on7 - If not applicable enter "0"

Number of 7on7 teams

7on7 Participants 9 and under

7on7 participants 12 - 10

7on7 participants 15-13

Limits of Liability

Directors & Officers coverage

Football Equipment Coverage

Crime Coverage

Estimated value of equipment

Choose limits