NEW YORK STATE SKI RACING ASSOCIATION - NORDIC, INC.

 

REQUEST FOR CERTIFICATE OF INSURANCE

 

            To obtain a certificate of insurance...

Complete the following information, (please print or type.):

 

Name ________________________________________ NYSSRA member # ______

 

Address (street/town/state/zip) _____________________________________________

 

Club ______________________________________________________________

 

____ This is for a number of club activities at one location (please attach a rough calendar of events)

____ This is for one event:

 

Name of Activity: ________________________________________________________

 

Date of Activity: _________________________________________________________

 

Location: _____________________________________________________________

 

Who must be named as additionally insured? _________________________________

 

Is the additional insured an owner or manager of the premises you want to use?

___ Yes ___ No

 

Certificates of insurance should be mailed to:

 

Name: __________________________________

 

Address: ________________________________

 

             ___________________________________

 

If more information is needed please contact: _________________________________

 

                                                           Phone: __________________________________

 

 Sign and Date this request: ______________________________________________

Then mail this to Merriam Insurance Agency, P O Box 1038, Schenectady, NY 12301

Or Fax it to Maggie Robbins, Merriam Insurance Agency 518-346-0996 ext. 208.

Or e-mail the requested information to maggie@merriaminsurance.com