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To be completed by BSA Leader Council Name:89: Greater Tampa Bay Area Address:13228 N. Central Avenue Tampa, FL 33612BOY SCOUTS OF AMERICATelephone Number: HSR Plaza 8138722691 4100 Medical Parkway Suite #200 ACE American Insurance Company Carrollton, TX 750071517 Toll Free 8667268870 Youth Youth & Adult LFL Family Fax 9725125820 P AR T 1 B S A C o u n c i l R e p r e s e n t a t i ve S t a t e m e n t1. PLEASE FULLY COMPLETE THIS FORM 2. ATTACH ITEMIZED BILLS WITH DOCTORS DIAGNOSIS 3
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