207687_Ruritan_Newsletter

RURITAN MEMBER CLUB INSURANCE CERTIFICATE REQUEST FORM (P LEASE P RINT C LEARLY )

RURITAN CLUB SPONSORING THE EVENT :___________________________________ C LUB A DDRESS : _____________________________________________________ C ITY : _________________________ S TATE : ______ Z IP C ODE : _____________ P HONE : _________________________ F AX : ___________________________ C ONTACT P ERSON : _____________________ E MAIL : ________________________ C ERTIFICATE H OLDER N AME : _____________________________________________ (N AME OF ENTITY REQUESTING THE CERTIFICATE OR PROOF OF COVERAGE - N OT YOUR CLUB !!) A DDRESS : _________________________________________________________ C ITY : _________________________ S TATE : ______ Z IP C ODE : _____________ D ESCRIPTION OF E VENT : _______________________________________________ _________________________________________________________________ B E SPECIFIC - D ESCRIBE YOUR INVOLVEMENT IN THE EVENT . S PECIAL ACTIVITIES SUCH AS PARADES , FIREWORKS , TRACTOR PULLS / INFLATABLES , ETC . ARE NOT AUTOMATICALLY COVERED AND WILL REQUIRE SPECIAL APPLICATIONS OR INFORMATION IN ORDER TO BE CONSIDERED FOR COVERAGE . D ATE ( S ) OF E VENT : ___________________________________________________ E VENT L OCATION : ____________________________________________________ _________________________________________________________________ N UMBER OF A TTENDEES : _____________ (I F GREATER THAN 2,000, EVENT MUST BE ADDED BY ENDORSEMENT ) D OES THE CERTIFICATE HOLDER NEED TO BE NAMED ADDITIONAL INSURED ? _____________ (I F SO , PLEASE PROVIDE COPY OF CONTRACT THAT SPECIFIES THIS REQUIREMENT )

S UBMIT THIS FORM TO : T HE B ALDWIN G ROUP A TTN : C AROL R OHDE

20 S OUTH K ING S TREET L EESBURG , VA 20175 P HONE : 703-737-2248 EMAIL : CAROL . ROHDE @ BALDWIN . COM

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