Insurance Certificate Request Form

FOR The Bass Federation, Inc (TBF) AFFILIATED CHAPTERS, FEDERATIONS, TOURNAMENTS & EVENTS

**You do not need to apply for an insurance certificate for every event. Only if someone else is requiring you to get one to  hold an event on their site or property. **

Fill out this online form below to submit your request for an insurance certificate. You can also still download and fax the PDF. CLICK HERE

CLUB INFORMATION

Club Number *

Name of Affiliated Club or Federation*

Club Representative & Title*

E-Mail Address*

Phone Number*

FAX #

Date of Certificate Request (Today):*

EVENT INFORMATION

Name of Event*

Date(s) of Event*

Hours of Event*

Location of Event*

Is there a request for a Certificate of Insurance or Additional Insured?*

IF YOU ONLY NEED PROOF OF INSURANCE, SKIP TO BOTTOM AND SUBMIT REQUEST

If Additional Insured is needed, fill out the info below

EXACT Name of Entity to be added, EXACTLY as it should appear on the policy:

Address

Relationship

Other, please explain

Is there an ADDITIONAL request for a Certificate of Insurance or Additional Insured?*

If Additional Insured is needed, fill out the info below

Name of Entity to be added as it should appear on the policy:

Address

Relationship

Other, please explain

*** Allow 7 business days for processing.

Request may be e-mailed, faxed or mailed to the attention of Nicki Lehrman (nicki.lehrman@kandkinsurance.com) or fax 260-459-5120 at K&K Insurance Group. OR

Mailed Attn: Nicki Lehrman, 1712 Magnavox Way, Fort Wayne, IN 46801-2338

Certificates will be e-mailed, faxed or mailed to you for distribution to any requested certificate holders or additional insureds. If special wording is required by a governmental entity or landlord, please also remit a copy of the permit or agreement. If there are any written agreements
regarding your event, please remit to ensure your certificate is processed correctly and promptly.***