Francis L. Dean & Associates
Insurance Application Form

Page 2 of 2


Premium Computation

Classification of Insured Persons # Eligible Rate Total Rate
 
1 ______________________________ ________ x ________ = ________
 
2 ______________________________ ________ x ________ = ________
 
3 ______________________________ ________ x ________ = ________
 
4 ______________________________ ________ x ________ = ________
 
Total Premium $_________

Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against and insurer, submits application or files claim containing a false or deceptive statement is guilty of insurance fraud. The accident medical insurance coverage is provided by American National Life Insurance Company of Texas, an American National Company, Legion Insurance Company, an MRM Company or Commercial Travelers Mutual Insurance Company. The liability coverage is offered through the Youth Sports Association Purchasing Group, pursuant to the Federal Risk Retention Act of 1996. Premium computation is subject to possible audit.

I understand that the premium is fully earned upon policy inception.

Applicant's Signature ______________________________     Date ____/____/____

Make check payable to "Francis L. Dean & Associates" and mail, along with both pages of this application, to:

    Francis L. Dean & Associates
    P.O. Box 4200
    Wheaton, IL. 60189

Or fax it to: (630) 665-7294. Questions? Call us at (800) 745-2409.
We will mail you a copy of your policy, along with a receipt.