Horse Club Certificate Request Horse Club Certificate Request "*" indicates required fields 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 Insurance Additional 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 Below Certificate 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 One Proof of Insurance Additional 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 Below Certificate Holder Name Mailing Address Street Address City State / Province / Region ZIP / Postal Code Attn: Fax NumberEmail Notes Δ