WALLEYES UNLIMITED OF MONTANA EVENT LIABILITY INSURANCE REMITTANCE FORM

Please fill out this form with your chapters’ information for each event that you have planned
for this year. At this time, there is no fee.

Your insurance coverage certificate will be mailed to you before your event(s).

If you prefer to use a paper printed application, please download here –> Liability Insurance Form

• If you need a rider for an event or any other insurance coverage questions, please call Julie DeMarsico at 406-899-8154 or email walleyesinsurance@outlook.com.
• If the facility where you hold your banquet has liability coverage of its own, please enclose proof of
  said coverage and the banquet fee may be waived.
• This form needs to be filled out with all of the events for the year that you anticipate having for the
  chapter with NO charge for the 3 main events – banquets, tournaments and kids days. Please email a
  copy of the events’ request form to Julie DeMarsico at walleyesinsurance@outlook.com.

Chapter or Tournament Name: *

Contact Email *

Date: *

Address: *

City, State & Zip: *

Submitting Officers’ Printed Name: *

First

Last

Phone Number: (no dashes or spaces please) *

"Banquet Event" –> Please provide the following information: Date – Estimated Attendance and Location.

"Kids Day Event" –> Please provide the following information: Date – Estimated Attendance and Location. If you have more than one event, please add all of them here.

"Tournament Event" –> Please provide the following information: Date – Estimated Attendance and Location. If you have more than one event, please add all of them here.

**Please use this field if an additional certificate is being requested or required for a facility with their name on it or for tournaments, if the BOR is requiring they are listed as additional insured.

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