2021-2022 IEA EVENT
INSURANCE REQUEST FORM

*required fields

Coverage Info.

Insurance provided by Equisure Inc. and will include 2 Setup/take down days automatically.

*Competition Days:	($140 per day)

Approved Additional Insureds: Landowner or Facility or Co-Hosting Team(s).
Horse Providers are automatically included so no need to list them.

Additional Insured 1 (optional)

Name:
Address:	Street Address:
Address:	City: State: Zip:
Interest (check all that apply):	Landowner Facility Horse Provider Co-Hosting Team

Additional Insured 2 (optional)

Name:
Address:	Street Address:
Address:	City: State: Zip:
Interest (check all that apply):	Landowner Facility Horse Provider Co-Hosting Team

Additional Insured 3 (optional)

Name:
Address:	Street Address:
Address:	City: State: Zip:
Interest (check all that apply):	Landowner Facility Horse Provider Co-Hosting Team

Additional Insured 4 (optional)

Name:
Address:	Street Address:
Address:	City: State: Zip:
Interest (check all that apply):	Landowner Facility Horse Provider Co-Hosting Team

Additional Insured 5 (optional)

Name:
Address:	Street Address:
Address:	City: State: Zip:
Interest (check all that apply):	Landowner Facility Horse Provider Co-Hosting Team