AERC Clinic Insurance

Insurance applications must be submitted at least 30 days prior to the clinic for processing. Clinic insurance is provided by Equisure, Inc., an insurance agency, in cooperation with AERC.

If you wish to have clinic information placed in Endurance News, 60 days notice is required.

Please send a PDF of your clinic flyer to endurancenews@aerc.org for linking to the AERC Education Clinic page.

Clinic name*

Clinic date(s)*

List names of all participating facilitators/clinicians. Include AERC number for members and contact information for non-AERC members.

Clinician 1 name*

E-mail*

AERC #*

Clinician 2 name (if any)

E-mail

Clinician 3 name (if any)

E-mail

Clinic location name*

Clinic address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Certificate holder 1*

Land ownerFacility

Name/Facility

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Certificate holder 2, if any

Land ownerFacility

Name/Facility

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Clinic insurance will be sent by email to the first facilitator/clinician listed above. If copies should be sent to any other people, please include information in the note box below. This is also the place to send any notes for the AERC office regarding your clinic.

Endurance 201 Clinics may include an AERC Introductory Ride. Opting to include an Introductory Ride in your clinic by checking the box below acknowledges that you will follow Introductory Ride rules as stated in the current AERC Rules and Regulations.

Yes, clinic will include an AERC Introductory rideNo AERC Introductory ride

Additional notes for the AERC office

Clinic type:

One Day "Endurance 101" Un-mounted Clinic ($20 co-pay)$20

One Day "Endurance 201" Mounted Clinic ($20 co-pay)$20

Overnight "Endurance 201" Mounted Clinic ($50 co-pay)$50

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

AERC Clinic Insurance Application