INSURANCE CERTIFICATE REQUEST
FOR The Bass Federation, Inc (TBF,INC.) AFFILIATED CHAPTERS, FEDERATIONS, TOURNAMENTS & EVENTS
Fax the request Nicki Lehrman 260-459-5120 or e-mail it to nicki_lehrman@kandkinsurance.com
It may also be mailed
to K&K Insurance Group, Attn: Nicki Lehrman,
1712 Magnavox Way, Fort Wayne, IN 46801-2338.
If
you have any questions, please contact K&K at (800) 441-3994.
Please Print or Type.
CLUB
INFORMATION: Club
Number
Name of State Federation/Affiliated Club/Federation Junior Club:
Club Representative & Title:
E-Mail Address:
Phone #:
FAX #:
Date of Certificate Request:
EVENT
INFORMATION:
Name of Event:
Date(s) of Event:
Hours of Event:
Location of Event:
Is there a
request for a Certificate of Insurance?
If yes, is the request for Proof of Insurance
only or for an Additional Insured? Please circle one. PROOF OF INSURANCE
ADDITIONAL INSURED
Name of Entity to be added as it should appear
on the policy:
Address:
Relationship (Mandatory): Sponsor Owner/Lessor of Premises
Other (Please explain):
Is there
another request for a Certificate of Insurance?
If yes, is the request for Proof of Insurance
only or for an Additional Insured? Please circle one.
PROOF
OF INSURANCE
ADDITIONAL INSURED
Name of Entity as it should appear on the
policy:
Address:
Relationship (Mandatory): Sponsor
Owner/Lessor of Premises
Other (Please explain):
