MIME-Version: 1.0 Content-Location: file:///C:/E970D0F1/2005_BASS_CERT_REQ.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" EVENT INSURANCE ENDORSEMENT & CERTIFICATE REQUEST

CERT= IFICATE REQUEST FOR B.A.S.S. NATIONAL FEDERATION TOURNAMENTS & EVENTS

 

***Please Print or Type.  Allow 5 to 7 business days for processing. Request may be e-mailed, faxed or mailed to t= he attention of Mechelle Trice at K&K Insurance Group. Certificates will b= e e-mailed, faxed or mailed to you for distribution to any requested certificate holders or additional insureds.  If special wording is required by a governmental entity or landlord, please also remit a copy of the per= mit or agreement. If there are any written agreements regarding your event, please remit to ensure your certificate is processed correctly and promptly.***

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Fax the request to Mechelle Trice = at (260) 459-5120 or e-mail it to mechelle_trice@kandkinsur= ance.com.

It may also be mailed to K&K Insurance Group, Attn: Mechelle Trice, 1712 Magnavox Way, Fort Way= ne, IN 46801-23= 38. If you have any questions, please contact us at (800) 441-3994.<= /span>

&nb= sp;

CLUB INFORMATION:

 

Name of State Federation/Affiliated Club/Federation Junior Club:         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;             &= nbsp;           &nbs= p;           &= nbsp;           &nbs= p;  

Club Representative & Title:        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                &= nbsp;           &nbs= p;            &= nbsp;          =             &nb= sp;            =               =             =       

E-Mail Address:   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;              &= nbsp;           &nbs= p;            &= nbsp;          =             &nb= sp;            =        

Phone #:         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;         &= nbsp;           &= nbsp;           &= nbsp;   FAX #:       &= nbsp;           &nbs= p;            &= nbsp;             &= nbsp;  

 

Date of Certifica= te Request:      &= nbsp;           &nbs= p;            &= nbsp;

 

 

EVENT INFORMATION:

 

Name of Event:          &= nbsp;           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          &= nbsp;   Date(s) of Event:     &nbs= p;              &= nbsp;           &nbs= p;            &= nbsp; 

 

Hours of Event:          &= nbsp;           &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          &= nbsp;   Location of Event:     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp; 

&nb= sp;

Is there a request for a Certifica= te of Insurance?  If yes, is the request for Proof of Insurance only or for an Additional Insured? Please circle one.        &= nbsp; PROOF OF INSURANCE             =          ADDITIONAL INSURED      =    

 

Name:   =             &nb= sp;            =             &nb= sp;            =                  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           

 

Address:          &= nbsp;           &nbs= p;         &= nbsp;           &nbs= p;            &= nbsp;          &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                    &= nbsp;           &= nbsp;  

Relationship:  Sponsor=               &n= bsp;          &= nbsp;           &nbs= p;           &= nbsp;   Owner/Lessor of Premises          &= nbsp;                   &= nbsp;           &= nbsp;           &= nbsp;    

Other (Please explain):  &n= bsp;            = ;            &n= bsp;                    &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;             

 

Is there another request for a Certificate of Insurance?  If yes, is the request for Proof of Insurance only or for an Additional Insured? Please circle one. PROOF OF INSURANCE             =       ADDITIONAL INSURED      =    

 

Name:   =             &nb= sp;            =             &nb= sp;            =                  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           

 

Address:          &= nbsp;           &nbs= p;         &= nbsp;           &nbs= p;            &= nbsp;          &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                    &= nbsp;           &= nbsp;  

Relationship:  Sponsor=               &n= bsp;          &= nbsp;           &nbs= p;           &= nbsp;   Owner/Lessor of Premises          &= nbsp;                   &= nbsp;           &= nbsp;           &= nbsp;    

Other (Please explain):  &n= bsp;            = ;            &n= bsp;                    &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;