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Mercer Consumer,a service of <br /> ME"MIRC11.Iiiii� Mercer Health&Benefits Administration LLC <br /> PO Box 14575 <br /> 11'.IR Des Moines, JA 50306 <br /> 6w lis the entity requesting to The inarned as an Addiflonal Insured? 111rips NO <br /> IM Does the addlitiloinall Insured own-the event location 'lid <br /> EJ No <br /> ................. <br /> o If no,please provilde explanation of rellationshilip between your club and the entity requesting the <br /> Additional liiinured sWus: <br /> & With regards,to this event is your clue bigroup: <br /> Ell'-flI Sponsoring [_711i IV 11 I'm 1:1 No <br /> ............. <br /> Volunteering 'vess NO <br /> Particip,91ing No <br /> R111 Yis's <br /> 7. Please list your/your club's function aindlor activities Forthe event(ExplainglLcftwhat your irole Is wkh <br /> respect to the event, More information is needed other than simply'sponsarin givolunteering): <br /> Ham radio special event station. Use of park[or-ation,use of Ham radio equipment in RVs <br /> S. Please explain the Additional Insured®s roWactions in the event, <br /> Owner of public past <br /> Fl..D? Is alcahol being served'? Yes ZNo <br /> is food belling served? Yiss Flo <br /> ,OCOD Is thhs an affileric event? No <br /> .]Yes <br /> ........... <br /> ire yollir iisfing trallers 1 rinobile eqitzlipmenvp <br /> ................... <br /> .................. <br /> oortziinti,,a IlMPriceiii Coijnsiiulmeil,"is lll,llnslli le <br /> reqiy <br /> ... .....mit= <br /> Signature: Data: <br /> Please fax or ernall'your request,to: <br /> Fax: :515 3&5 30D5 <br /> Eniall,RLs_dAL&,,�m_ rv�icerne�ircerxoim <br /> in CA diNa Mercer Healitih&Benefits Insurance Services LLC <br /> AR Ins.lUc.ON3439 <br /> CA Ins.ILIc.,ODG39709 <br /> ITALFAT-HIMTH� ;RFnREMEhrr-aurVESTMENM <br /> 10 <br />