Request Special Event Certificate of Insurance

Fill out this app if you would like to add an event to an existing certificate.

Name of Applicant or Insured *
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Contact Name *
First Last
Contact Phone# *
### - ### - ####
Email where certificate is to be sent *
Send to a club member, do not send directly to the landowner

Confirm
Event Location *
Event date - Start Date *
End Date *
Land Owner Details
Landowner (Name) *

Provide the fill legal name of the landowner/town/municipality ect.
Landowner Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

this is the business or home address of the Landowner. NOT THE PROPERTY ITSELF unless the two are the same.
General Comments (if required)
Applicants Signature *
Name of signature above *
First Last
Date Signed *
By checking the box below you are certifying the information contained within this form to be accurate and correct. *

I understand and agree