SPORTSMEN'S INSURANCE CERTIFICATES
Request for certificate of insurance should be done at least six weeks prior to the trial. For additional
insurance
information call Sportmen's #315-654-2068.
The policy provides liability coverage for an aggregate of $2 million,
$1
million for each occurrence, $50,000 for damage to the rented premises and
medical payments of $5,000
each person. Make check for $50.00 for additional insurance for
Land/Facility Owner and mail to
Sportmen’s Insurance along with form. Address below.
Thanks, Francis Raley
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REQUEST FOR CERTIFICATE OF INSURANCE
(PLEASE COMPLETE FOR LAND/FACILITY OWNERS OR
LESSOR/SPONSOR REQUIRING THE CERTIFICATES
Name of Club: United States Border Collie Handlers Association ________________________________________________________________________________________ Complete Club’s Mailing Address: 2915 Anderson Lane, Crawford, Tx. 76638 ________________________________________________________________________________________ Contact Name: __Francis Raley_ Phone Number: _254-486-2500 Fax Number: 254-486-2271 Need no Later Than: _______________________ Is this certificate for a permit? ___x__ 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: Street:
___________________________________________________________________________________________________________ LAND/FACILITY OWNER OR LESSOR/SPONSOR MAILING ADDRESS Attn: _____________________________________________________________________________________________________ Street: __________________________________________________________________________________________________________ City, State, Zip: ____________________________________________________________________________________________________ Fax Number: _____________________________________________ E-Mail address: ___________________________________ PLEASE CHECK ONE OF THE FOLLOWING: PROOF OF COVERAGE ONLY_______________ ADDITIONAL INSURED __________$50.00_____ Please refer to your contract in choosing the appropriate type of certificate You may mail, fax or e-mail requests to: SPORTSMEN’S INSURANCE AGENCY PLAN, INC. PO BOX 799 CAPE VINCENT, NY 13618 315-654-2068 315-654-3097 –FAX 315-654-2334 – FAX dcookson@dogclubinsurance.com cdisotell@dogclubinsurance.com mjbrown@dogclubinsurance.com
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