W.W.S.C.C. Event Insurance Application

NOTE: This application must be completed in full and delivered to the WWSCC Insurance Focal no later than three (3) weeks prior to your event date, or no less than two weeks prior to the site owner(s) deadline for receipt of the insurance certificate (whichever is earlier). Failure to provide all of the information in a timely manner will, as K&K Insurance says, result in NO COVERAGE. The WWSCC Treasurer must have received the insurance payment no less than two weeks prior to the event. Once coverage has been secured, cancellations or changes in date/location/etc. can be accepted up to four days prior to the originally scheduled date of the event.

Club Name(s):

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Event Date(s):

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Event Chair(s):

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Event Location (specific name of site and street address of site):

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Event Type (autocross, rally, car show):

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Names of required Additional Insureds (verify this with your site owner/operator):

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Insurance certificate required by (name, mailing address or FAX number):

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Name and phone number of focal for event waivers:

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Insurance Focal for 2003: Karen Babb, 14337 S.E. 163rd St., Renton WA 98058.