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

CityState / Province

Postal / Zip CodeCountry

Contact Person *

Contact Phone Number*

Area CodePhone Number

E-mail*

Preferred form of contact

PhoneEmail

Need certificate no later than*

Date

Is this certificate for a permit?*

YesNo

Will you have foreign competitors, decoys or judges attending your trial*

YesNo

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 feeNo - 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

CityState / Province

Postal / Zip CodeCountry

Name of Additionally Insured (if requested)

Address of Additionally Insured (if requested)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

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*

MonthDayYear

End Date of Event*

MonthDayYear

Start Time of Event*

:HourMinutesAM/PM Option

End Time of Event*

:HourMinutesAM/PM Option

Address where event is to be held*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Signature:*

Date*

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*

Certificate of Coverage Administrative Fee Only$75.00

Certificate of Coverage Administrative Fee and Additional Insured$125.00

Total $0.00