Certificate of Insurance
Request form
Effective January 1, 2008
to December 31, 2008
Club Name: ___________________________________________
Club Contact: _________________________________________
Club Address: _________________________________________
_________________________________________
Club Phone: _________________________________________
Additional Insured Party Information:
If additional insured is other than a landowner, please specify relationship: _____________
Date of Event: _______________________________
Event Site: ___________________________________________________________
Name of Additional Insured Party: ___________________________________________
___________________________________________
Address of Additional Insured: ______________________________________________
Street
______________________________________________
City St Zip Code
Please Note: If you need more than one additional insured, please complete the second page of this form. The original insurance certificate(s) will be sent to the club contact. The club contact is responsible for sending copies of certificates of insurance to the additional insureds as needed.
Please e-mail/scan, fax or mail this form to the certificate administrator:
Bollinger Insurance
Attn: Chirag Patel
E-mail: Chirag.Patel@bollingerinsurance.com
Fax: 973-921-2876
Phone: 800-350-8005, ext. 8184
I affirm that my club is currently chartered with the United States Orienteering Federation (USOF). I understand that a copy of this certificate will be mailed to USOF’s home office to verify my club’s official chartered membership status.
______________________________________________ ___________________
Name of Authorized Club Member Date
Page Two
Club Name: _____________________________________________
If additional insured below is other than a landowner, please specify relationship:
_______________________________________
Additional Insured Name: __________________________________________________
__________________________________________________
Address: ________________________________________________________________
Street
________________________________________________________________
City State Zip Code
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If additional insured below is other than a landowner, please specify relationship:
________________________________________
Additional Insured Name: __________________________________________________
__________________________________________________
Address: ________________________________________________________________
Street
________________________________________________________________
City State Zip Code