2022 Request for Certificate of Insurance

USMRA Request for Certificate of Insurance

2023 USMRA Sanctioned Events

Club Name Hosting Trial *
Additional Club Name Hosting Trial
Club's Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Person *
Contact Phone Number *

Area Code Phone Number
E-mail *
Preferred form of contact

Phone Email
Need certificate no later than *

Month Day Year
Date
Is this certificate for a permit? *

Yes No
Will you have foreign competitors, decoys or judges attending your trial *

Yes No
If foreign competitors, decoys or judges are attending, please list their name and what they will be participating as
Are you requesting to add additionally insured, such as a school, property owner, government official, etc? *

Yes - Add additional insured - $50.00 additional fee No - Proof of Coverage Only - $75.00 fee
CERTIFICATE HOLDER INFORMATION
LAND/FACILITY OWNERS NAME OR LESSORS/SPONSORS: *
Land/Facility Owner or Lessor/Sponsor Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Additionally Insured (if requested)
Address of Additionally Insured (if requested)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Please include all dates that you plan on having open field, training seminars, trials or any other event sanctioned by USMRA.
Start Date of Event *

Month Day Year
End Date of Event *

Month Day Year
Start Time of Event *

: Hour Minutes AM/PM Option
End Time of Event *

: Hour Minutes AM/PM Option
Address where event is to be held *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Signature: *
Date *

Month Day Year
Date
The $75.00 administrative fee is for the process of sanctioning and supervising your USMRA venue. If you are requesting to add additional insured, there will be an additional $50.00 charge,
Hard Copies with checks made to "USMRA" for $75.00 or $125.00 for additional insured can be sent to: Maureen Haggerty, USMRA Treasurer, 565 Midwest Trl N, Lake Elmo, MN 55042
My Products *
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Certificate of Coverage Administrative Fee Only $ 75.00

Certificate of Coverage Administrative Fee and Additional Insured $ 125.00

Total $ 0.00
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