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Insurance Form

1. If a Land/Facility Owner requests a "Proof of Insurance" for a Branch Event, fill out the form below and submit.

2. If the Land/Facility Owner requires to be added as an "Additional Insured", check the "Additional Insured Certificate" box below, complete the form and submit

These certificates will be sent directly to the land/facility owner(s) requesting the coverage.

Please submit both of these requests 30 days (not less than 10 days) prior to the date the certificate is needed by the landowner. The insurance agent needs the time to process these requests. Requests made at the last minute may not be able to be processed by the time you need it! (see question 19 on the Q&A)

Do you need an "Additional Insured Certificate"? (Note: if you choose yes, the land/facility owner automatically gets both certificates.)

Do you need a "Proof of Insurance Certificate"?

Branch #

Contact Name:

Contact E-mail:

Contact Phone:

Contact Address:

Contact City, State, Zip:

Date the insurance is needed no later than (MM /DD/YYYY):

Event Name:

Beginning Date of Event (MM/DD/YYYY):

Beginning Time of Event (HH:MM):

Ending Date of Event (MM/DD/YYYY):

Ending Time of Event (HH:MM):

Venue/Place Name where event will be held:

Address of Venue:

Venue City, State, Zip:

Land/Facility Owner Name:

Attention (Name):

Land/Facility Owner Address:

Owner City, State, Zip:

Land/Facility Owner Phone:

Land/Facility Owner Fax:

Land/Facility Owner Email:

Specific wording:

 

Submitted by:

Position:


 

Questions:

If you have any questions regarding our insurance, such as information on Insurance coverage, and requests, information on insurance non-coverage related questions, such as form submittal problems, or if you have problems resolving a problems with our insurance agent, contact:

Dick Tombrink
2250 North 12th Road
Worden, MT 59088
(406) 967-6687
dicknsue@nemontel.net