On line Form - CRDi IAP Accident Insurance

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This is for CRDi insurance.
Below is the info for email transfer the bank will ask you.
Please fill in the below form and email transfer funds to: bgfhoochie@gmail.com
Name of person you are paying : CRDi
Bank Security question to ask: What is the best sport
Answer: rollerderby2012
In the comments field of the email transfer please state the skater name and league they belong to to confirm the insurance payment and so we can match the records.

If paying by money order.
Money order is to be made to
CRDi
#200, 33 Blackfoot Road
Sherwood Park
Alberta, Canada
T8A 4W5

We do not accept personal checks, paypal or credit card.

We will email you the insurance number once payment is made.
We will also mail you an insurance card to keep in your wallet as proof of insurance.

Thank you

Province you live in *

Last Name *

Skater First Name *

Derby Name - leave blank if skater has not picked one *

Street Address *

City you live in *

Postal Code *

Skater date of birth *

Female or Male *

Male

Female

Name of league you skate with *

Type of skater *

Skater

Jr Skater

Official (ref)

Provincial health Care # (mandatory for CRDinsurance) *

Email address

Comments - amount being paid - email transfer/money order

Submit

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