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Mercer Coinsumer, a service of <br /> Mercer Health&Beneft Adirninistration LLC <br /> M011111 111111[1] �ayn� <br /> PO lBox'14575 <br /> 11 if� <br /> ............ <br /> IDes Moines, K 50306 <br /> . Ills the eintity rein uuYr IlioreinIll e inarned as an Addfitkx-sal litsured? res NO <br /> ..........: <br /> [.131 Does the addiflonall Insured own thiii-D.event [.iocation? F.] 1h,10!'!................ <br /> o If no,please provide explanation of relationship between your club and the entity requesting the <br /> Additional Insured status: <br /> S. With regards to this event Is your clubigroup: <br /> Sponsoring Z Yes E]No <br /> Volunteering Elyes No <br /> Participating [2]Yes Ej No <br /> 7. Please list your/your club's function and/or activities for the event(Explain 9fflqULwhat your role Is with <br /> respect to the event.More information is needed other than simply'sponsoring/Volunteering): <br /> Ham radio special event station. Use of park location,use of Ham radio equipment in RVs <br /> S. Please explain the Additional Insured's rolefactions in the event: <br /> Owner of public pwic <br /> Is alcohol in served? [:]Yes R]No <br /> Is food being served? E]Yes R]No <br /> ED Is thts an athletic event? 0 Yes [zNO <br /> El Are you using trallers I mobile equipment? E]Yes ZNo <br /> I'm 1YPfmilan Ilk RA"4110-011'r 11COlinsuilme'lir IS 1,1113011-111111,111 In <br /> MQNG—St&"* <br /> Signature, Oate:, <br /> Plessef,=01111--eiiriaafl',you ir inqiupstto: <br /> Fax16,16=5L.."113006 <br /> Eiiriallk RRIOIYM!�p�evjc� "�meL&W, <br /> In CA dibla Mercer Health&Benefits Insurance Services LLC <br /> AR Ins.LIc.0303439 <br /> CA Ins.Uc.ODG39709 <br /> TNENT,� MA93H a&EMWENTthYMMUM <br />