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Request for Additional Insured / Certificate of Insurance Mail to: Abe Far, GSBF, 2451 Galahad Road, San Diego, CA 92123 Or email to: Abe Far at AbeFar@cox.net Allow 3 weeks for processing – SUBJECT TO UNDERWRITING APPROVAL Club’s Name: ______________________________________________________ Representatives Name: _____________________________Title: ______________ Address: __________________________________________________________ City: ___________________________________State: ________Zip Code______________ Day Time Phone: ( ) _______________ Eve Phone: ( ) ________________ Fax: ___________________________________E-Mail: _____________________ Name and mailing address of the person or organization that has requested that you provide Proof of insurance and/or additional insured. (Certificate Holder) Name: ____________________________________________________________ Address: _______________________________Phone: ( ) ________________ City: ___________________________ State: ________ Zip Code: ____________ Check: _____ Certificate of insurance (proof of insurance) _____ Additional insured requested (attach any instruction) _____ Special form or wording required (please attach) Interest of certificate holder: Landlord/Lessor ______ Funding Source _____Govt. or Agency permit_____ Work done on their behalf ______ Other______________________________ Please call if any questions: |
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