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Insurance Form
  1. This form MUST be used to obtain liability insurance coverage for ABTC events (e.g. shows, trials, matches, seminars) held in the name of the ABTC. ABTC insurance is only for liability coverage (no workman's comp) and covers both the hosting group's ABTC members and any other individuals assisting them. Forms must be submitted 10 days or more in advance of the date of your event(s) for EACH INSURED. If there is more than one insured, please submit all forms at the same time.

  2. About your club

  3. Requester's Name(*)
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    Name of the person responsible for this insurance request for the hosting club.
  4. Requester's Email(*)
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    Email of the person responsible for this insurance request for the hosting club.
  5. Hosting Club(*)
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    Enter the name of the local club hosting the event.
  6. Club's Street Address(*)
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    Enter the club's address. Address should include zip code. Include fax number(s) when available.
  7. Club's Fax#
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    Enter the club's fax number if it is available.
  8. Club's City(*)
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    The club's city.
  9. Club's State(*)
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    Select the club's state.
  10. Club's Zip Code(*)
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    Enter the club's zip code.
  11. Club's Phone#
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    Enter the club's phone number if it is available.
  12. Date Certificate is Needed(*)
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    Enter the date by which you need the certificate (mm/dd/yyyy).
  13. Event Information

  14. Event Start Date(*)
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    Enter start date for your event (mm/dd/yyyy).
  15. Event Stop Date(*)
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    Enter ending date for your event (mm/dd/yyyy).
  16. Event Name(*)
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    Enter the Name of the event (This must read \"ABTC .......\"
    like \"ABTC Obedience Trial\" or \"ABTC Conformation & Agility Trials.\" Your clubs' name must not appear in the event's name, nor may it appear in any premium list or advertising. (No PO boxes)
  17. Event Street Address(*)
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    Enter the street address of the event
  18. Event City(*)
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    Enter the city of the event.
  19. Event State(*)
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    Select the state where the event will be held.
  20. About the Insured

  21. Facility Owner's Name(*)
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    Enter the facility owner's name. Certificates are normally sent to the facility / owner of the property.
  22. Event Zip Code(*)
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    Enter the zip code where the event will be held.
  23. Facility Owner's Street Address(*)
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    The primary address where a certificate will be sent. This is typically the facility owner's street address. Address should include zip code. Include fax number(s) when available.
  24. Facility Owner's City(*)
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    The city of the facility owner
  25. Facility Owner's State(*)
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    Select the facility owner's state.
  26. Facility Owner's Zip Code(*)
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    Enter the facility owner's zip code.
  27. Facility Owner's Email
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    Facility owner's email if it is available.
  28. Facility Owner's Fax#:
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    Enter the facility owner's fax number if it is available.
  29. Additional Insured(*)

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    Is there an additionally insured party?
  30. Additionally Insured's Name
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    The name of the additionally insured to send the certificate to.
  31. Additionally Insured's Street Address
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    The additionally insured's street address where a certificate will be sent. Address should include zip code. Include fax number(s) when available.
  32. Additionally Insured's City
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    The city of the additionally insured party.
  33. Additional Insured's State
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    Select the additionally insured's state.
  34. Additionally Insured's Zip Code
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    Enter the additionally insured's zip code.
  35. Additionally Insured's Email
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    Additionally Insured's email if it is available.
  36. Additionally Insured's Fax#
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    Enter the additionally insured's fax number if it is available.
  37. Comments
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    Please enter any additional comments as needed.
  38. Invalid Input
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