More Information

Name and/or club name:
Person to contact:
Position held:
Address:
	City: State: Zip:
Daytime Phone #:
Fax #:
E-mail:
Number of Members:
Is your club incorporated?	Yes No In What State
Has your club had insurance with us before?	Yes No If yes, how long ago?
Do you use live ammunition?	Yes No
Do you do breed rescue?	Yes No If yes, we can not write the Commercial General Liability Coverage.
Please provide a brief description of your activities:
What type of insurance are you interested in?	Commercial General Liability Special Risk Accident Business-owners Kennel Business-owners – Trainers Fidelity Bonding Directors & Officers Liability Must be quoted and cleared with the underwriter Coverage Not available in all states or in Puerto Rico and Canada*

Sportsmen's Insurance Agency Plan, PO Box 799, 170 E. Broadway Street • Cape Vincent, NY 13618-0799 • 315-654-2068 • 315-654-3097 (fax)