Certificate of Insurance Request Form Name of Requesting Affiliate: Club Contact person for this event: Street Address Daytime Phone Number: Evening Phone Number: Approximate number of members that will attend: Type of event: Date of event Will bleachers be used? Yes No Will you be signing a lease of premises or contract? Yes No (A copy of the contract must accompany this request.) Location of Event: Name: Address: City, State Zip Owner of the premises where the event will be held: Certificate to be mailed to: Name: Address: City, State Zip Special Instructions: JCNA Affiliate Instructions: Fill all requested information and mail one copy each to: J.C. Taylor Insurance, Inc. Jaguar Clubs of North America 320 69th Street JCNA Business Manage/Insurance Upper Darby, PA 19082 500 Westover Dr. #8354 Sanford, NC. 27330 SC01@JCNA.com For additional information contact: Loretta Dearing (800) 272-6784 Fax: (610) 853-3823 Request for a Certificate of Insurance ins_req (Rev 09/12/2015) Jaguar Of North America, Inc.
Certificate of Insurance Request Form Name of Requesting Affiliate: Club Contact person for this event: Street Address Daytime Phone Number: Evening Phone Number: Approximate number of members that will attend: Type of event: Date of event Will bleachers be used? Yes No Will you be signing a lease of premises or contract? Yes No (A copy of the contract must accompany this request.) Location of Event: Name: Address: City, State Zip Owner of the premises where the event will be held: Certificate to be mailed to: Name: Address: City, State Zip Special Instructions: JCNA Affiliate Instructions: Fill all requested information and mail one copy each to: J.C. Taylor Insurance, Inc. Jaguar Clubs of North America 320 69th Street JCNA Business Manage/Insurance Upper Darby, PA 19082 500 Westover Dr. #8354 Sanford, NC. 27330 SC01@JCNA.com For additional information contact: Loretta Dearing (800) 272-6784 Fax: (610) 853-3823 Request for a Certificate of Insurance ins_req (Rev 09/12/2015) Jaguar Of North America, Inc.
JCNA%20Slalom%20Rules%20Revision%20%204-28-2017%20JDH%20v4%20JCL%20Edits%2020180408.docx