Application For Membership

  
     


This Application is for:

2011 - 2012 Policy
April 25, 2011 to April 25, 2012 - $215.00 per person
October 25, 2011 to April 25, 2012 - $150.00 per person
Note: This reduced premium option will be processed one week prior to the start date.
January 25, 2012 to April 25, 2012 - $110.00 per person
Note: This reduced premium option will be processed one week prior to the start date.
March 25, 2012 to April 25, 2012 - $50.00 per person
Note: This reduced premium option will be processed one week prior to the start date.
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Single Event - $125.00 per person (Limited to 7 Consecutive days)
      Dates of event:
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2010 - 2011 Policy
March 25, 2011 to April 25, 2011 - $50.00 per person

  • Fill in the information below COMPLETELY.
  • Print out the application & mail with your check.
  • Make your check or money order made payable to Performers of the U.S.
  • Note: Hypnotists MUST also include a safety class certificate of completion with the application if you do not have one on file.  See the Safety page for more information.
  • Mail to:  Specialty Insurance Agency
  • P.O. Box 24
  • New Richmond , WI 54017-0024
 

 

Application Form:

  
   
First Name:
 MI:
 Last Name:
Performers Name(s) And Or Business Name:
Referred By:
Street Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Fax:
Email Address:
Description of what you do:
Event Dates:
   
Coverage is subject to all terms, conditions and exclusions as stated in the insurance policy
   

Signature:
   
Date:
   
 
     
   

      


 
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Specialty Insurance Agency
Performers of the US & Vendors of the US
PO Box 24
New Richmond, WI 54017
Ph: 715.246.8908
Fax: 715-246-4257
info@specialtyinsuranceagency.com