ISR Super Excess Medical Insurance





Super Excess Medical Insurance --- $130.00

ISR has an additional insurance policy in place for it's members. This policy has the following limits:
	Medical Limits: $100,000
	Accidental Death and Dismemberment: $5,000
	Dental: Included in Maximum Medical Benefit
	Deductible: $5,000 Disappearing Deductible

Please allow 3 business days for processing the enrollment form. Coverage will become effective on the date
the application is submitted to Frazier Insurance and will be effective until 08/31/2010. Please submit the
enrollment form to:
	Frazier Insurance Agency, Inc.
	Location: 8002 Discovery Drive, Suite 415, Richmond, VA 23229
	Mailing: P.O. Box 1250, Midlothian, VA 23113-1250

First Name:			Last Name:
Address:
City:		State/Prov:		Zip Code:
Day Phone:			Evening Phone:
Mobile Phone:			Fax:
Email:
Date of Birth:	Month: Day: Year:

By signing below I agree to the terms and conditions listed and understand that this policy is only valid at ISR
sanctioned events:



Racer Name -Print		Racer Name - Signature		Date