Horse Club Certificate Request Horse Club Certificate Request Name of Club*Club Contact* First Last Club Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Email Telephone NumberFax NumberCertificate Needed By*Certificate Holder #1Provide Certificate Holder Details BelowSelect One*Proof of InsuranceAdditional Insured (will require additional premium)NOTE: Please refer to your contract in selecting the appropriate type of certificate.Check all that apply* Landowner Facility Owner Sponsor Equipment Lessor Other If "Other" Describe BelowCertificate Holder Name*Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Attn:Fax NumberEmail NotesCertificate Holder #2 (if necessary)Provide Certificate Holder Details BelowSelect OneProof of InsuranceAdditional Insured (will require additional premium)NOTE: Please refer to your contract in selecting the appropriate type of certificate.Check all that apply Landowner Facility Owner Sponsor Equipment Lessor Other If "Other" Describe BelowCertificate Holder NameMailing Address Street Address City State / Province / Region ZIP / Postal Code Attn:Fax NumberEmail Notes