Belgian Sheepdog Club of America
Belgian Sheepdog Club of America
Belgian Sheepdog Club of America

National Specialty Guidelines – Appendix B Request for Certificate of Insurance

REQUEST FOR CERTIFICATE OF INSURANCE

(Please complete for Land/Facility Owners or Lessor/Sponsor requiring the Certificates for club events)

Name of  Club: ______________________________________________________________________

Complete Club’s Mailing Address: _______________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Contact Name: ______________________________________________________________________

Phone Number: _____________________________________Fax Number: ______________________

Need no Later Than: _________________________________

Is this certificate for a permit?   ______  YES    _____  NO

CERTIFICATE HOLDER INFORMATION

LAND/FACILITY OWNERS NAME: ______________________________________________________

(Please include any specific wording required by your contract with the land/facility owner)

OR

LESSOR/SPONSOR: __________________________________________________________________

NAME OF EVENT: ___________________________________________________________________

DATES OF EVENT: ___________________________________________________________________

ADDRESS WHERE EVENT HELD:

Street: ______________________________________________

City, State: __________________________________________

LAND/FACILITY OWNER OR LESSOR/SPONSOR MAILING ADDRESS

Attn: _______________________________________________

Street: ______________________________________________

City, State, Zip Code: __________________________________

Fax Number: _________________________________ Email Address: __________________________

PLEASE CHECK ONE OF THE FOLLOWING:

PROOF OF COVERAGE ONLY __________            ADDITIONAL INSURED ___________

(Please refer to your contract in choosing the appropriate type of certificate)

Please mail or fax the request to Equisure, Inc

Attn: AKC Program

13790 E Rice Pl Ste 100

Aurora CO 80015

Phone 800-752-2472 Fax 303-614-6967