REQUEST FOR CERTIFICATE OF INSURANCE

 (PLEASE COMPLETE FOR LAND/FACILITY OWNERS OR LESSOR/SPONSOR

REQUIRING THE CERTIFICATES FOR CLUB EVENTS)

 Name of Club:__________________________________________________________________________________

 Complete Clubs Mailing Address:  USBCHA, 2915 Anderson Lane, Crawford, Tx.  76638

Contact Name:__________________________________________________________________________________

Phone Number:___________________________________   Fax Number:_________________________________

Need no Later Than:_____________________________________________________________________________

 Is this certificate for a permit?  ____________Yes   ____________No

CERTIFICATE HOLDER INFORMATION

Land/Facility Owners Name:______________________________________________________________________

Please included any specific wording required

OR

Lessors/Sponsors:_______________________________________________________________________________

_______________________________________________________________________________________________

Dates and Times of Event:________________________________________________________________________

ADDRESS WHERE THE EVENT IS TO BE HELD

Stree:__________________________________________________________________________________________

City, State:_____________________________________________________________________________________

LAND/FACILITY OWNER OR LESSOR/SPONSOR MAILING ADDRESS:

Attn:__________________________________________________________________________________________

Street:_________________________________________________________________________________________

City/State, Zip:_________________________________________________________________________________

Please check one of the following: Proof of coverage only____________Additional insured________________