K&K Insurance Group, Inc. 1712 Magnavox Way Fort Wayne, IN 46804 Phone 1-800-426-2889 Fax 1-260-459-5105 Claims 1-800-237-2917 Application Date : 4/15/2015 FinalSummary AmateurSportsTeams&Leagues Insured Information Are you an insurance agent Yes or broker: Named insured (as it should Otters Swim Team appear on the policy): Doing business as (DBA): Contact first name: Stepanie Contact last name: LaPorta Mailing address: 1106 Hummingbird Circle City: Joliet State: Illinois Zip: 60431 Phone: 630-728-4541 Fax: Cell: 630-728-4541 E-mail:
[email protected] Web site: This is a new account Agent Information Agency name: Mesirow Financial Agency mailing address: 353 N. Clark St. City: Chicago State: Illinois Zip: 60654 Agent/contact first name: Pamela Agent/contact last name: Kopeika Agency Agency phone: 312-595-8218 Fax: Agent/contact e-mail:
[email protected] I do NOT wish to receive a gfedc commission General Liability Eligibility Selected operations Swimming Coverage effective date 4/24/2015 to 4/24/2016 Is the organization a/an: League and/or club What is the total number of teams in the league? 137 Is the insured a member of any of the following organizations? American Youth Football, American Amateur Baseball Congress, Babe Ruth/Cal Ripken Baseball, Babe Ruth Softball, Dixie Boys Baseball, Dixie Softball, Dixie Youth Baseball, U.S. Youth Soccer Association, None World Adult Kickball Association (WAKA®), Soccer Association for Youth, USA (SAY Soccer), Pop Warner In which state is the team or league based? Illinois