USBCHA Trial Insurance

Insurance Form- USBCHA

See Insurance instructions or contact treasurer@usbcha.com if you have any questions

Request for Certificate of Insurance
Please Complete for Land/Facility Owners or Lessor/Sponsor Requiring the Certificates for Club Events
For more detailed information see the Insurance Directions posted under the on-line insurance form
United States Border Collie Handlers Assoc. (USBCHA)
Contact Information:
Marianna Schreeder, Treasurer
3195 Lee St SE
Smyrna, GA 30080
Phone: 678-296-1069
Fax: 1-855-950-6666
Email: Treasurer@USBCHA.com
Need No Later Than*
(to be filled in by trial host)
Date Format: MM slash DD slash YYYY
Certificate Holder Information
Land/Facility Owners Name or Lessors/Sponsors*
(Please include any specific wording required)
Address where the event is to be held*
Street Address City State ZIP Code
Date Event Begins*
Date Format: MM slash DD slash YYYY
Date Event Ends*
Date Format: MM slash DD slash YYYY
Name of Contact*
Mailing Address*
Street Address City State ZIP Code
Phone
Fax
Email
Additional Comments, Notes or Request
Add any information you think is pertinent to the request:
Please choose one of the following*
- Additional Insured
- Proof of Coverage only (no fee)
Payment Choice
- PayPal ($78)
- Check or Money order to be mailed ($75)
PayPal
You can either directly pay $78 to USBCHA through PayPal or have treasurer send you an invoice that you can. Please select which method you intend to use.
- Pay $78 to USBCHA via PayPal
- Please send me an invoice to email below
Send invoice to
Email address for invoice
Check or Money order-Put name of trial on check
$75.00 Check Payable to USBCHA Mail to:
Marianna Schreeder, Treasurer
3195 Lee St SE
Smyrna, GA 30080

Insurance Form- USBCHA

Request for Certificate of Insurance

United States Border Collie Handlers Assoc. (USBCHA)

Certificate Holder Information

Check or Money order-Put name of trial on check