Rochester Area Federation Insurance form 1

FORM FOR ADDING MEMBER(S) TOTHE CLUB MEMBERSHIP INSURANCE ROSTER For 2006

CLUB NAME

First Name		Last Name
Your Email
FEDERATION

is this the first additional member report Yes No, if no, enter date of last report

No. or current insured members reported No.of Additional members to be insured

1 First Name(s) Last Name

2 First Name(s) Last Name

3 First Name(s) Last Name

4 First Name(s) Last Name

5 First Name(s) Last Name

6 First Name(s) Last Name

The Fee of $4.10 times the increase in membership (that exceeds 11)$____._____ is to be made out to the Rochester Area Federation
OR
Send the form and check to RAF Insurance Rep. Don Hunger, 1097 Manitou Rd., Hilton, NY, 14468

Authorization Number _________

Copyright © 2000 [Rochester Area Federation ]. All rights reserved.
Revised: November 10, 2005

1 First Name(s)		Last Name
2 First Name(s)		Last Name
3 First Name(s)		Last Name
4 First Name(s)		Last Name
5 First Name(s)		Last Name
6 First Name(s)		Last Name