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<br />JAN 09 2004 09:49 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br />02t9l/U4: .ra.L 1.1#.... ....... -- - .-.. <br />'.TJ ~hiM~I~~ <br /> <br />P.12/16 <br /> <br />REQUeST FOR LIONS CERTIFICA TeS OF INSURANCE <br />......NOTE: WE REQUIRE 7 B'l8'NES'~ TO PROCESS THIS REQUEST....... <br />Date 1-1-04- <br />Thle form can either be faxecl or maUacI to T. ,j. Adame Group, LLC <br /> <br />Acldre..: 333 E. Butterfield Rd., Ste. 100 <br />Lombarcl,'IL 80148 . <br />Attn: Marcl Ray.. <br /> <br />CLUB INFORMATION: <br /> <br />FUtI: (830)324-2781 <br />Attn: Mare. Reye. <br /> <br />NameofLlonlOlub ~..J~~Il_....a L-Ib\-I$ ,/, wi? <br /> <br />AddrN' <br /> <br />'7, '5';;- i3:i2-~ 'i:::>2..,~t$ <br /> <br />CI\y, $Wte, Z1, L-1&~ei:4l.' . ~ ,M...j '7'7 e>'3>B <br /> <br />eveNT INFORMATION: <br /> <br />Event 'L..~ p, SoI-"I::l....!?~ ~~$i <br /> <br />_el) of Event <br />LOClltlon of Event <br /> <br />~kr~~I'o,,! 'Fie;;P-v~7' '7ft1 <br /> <br />Le-L..r,€i'" IJ,~ ..-A1Le: <br /> <br />CERTIFICATE HOLDERJADDIT'iONALINSURED INFORMATION: <br /> <br />Cert/flCllte Holder: <br />. (party reqlllrlng <br />certificate from <br />your club) <br /> <br />~cil>~"" t:::,~-:! ~~j2.1P~/ A!-J~lU\ <br />~D j::L :::r~ L-A~..-;o:. B~ ~fD. <br />il'\...ii?.e>Vetl. ~,...\ C?73l>4 <br />, <br />1i:."3 -").::74- .4<?~ <br /> <br />~'7 <br /> <br />A/ldll/onellnsurads: (In order to be I" addltlonll in.urld, the PII1Y mUlt own the premlas. on willen you <br />ar. conducting laut sv."t ~ . pub lie body Iaaulng . p'[!!llt): <br />U Nons ..a Same .. Certltlclte Hold.r W Different from Clrt. Holder <br /> <br />MAILING/FAX INFORMATION: <br /> <br />RequlIsted B~: b"'2..e&. tL\ce~~..~~ <br />Phone'whlll'B YOII can be r.achecl rorque'llons: '-'12-- z..'2-1-"91"2.2- <br /> <br />/ <br /> <br />h.oeJ- ~~~~~ <br />"'71 c;;.<;; ~-.. "C>;2...\i.? <br />.c..~z.vi....-.4,...w '97 078 <br />~F8X Number: "/b'7 -'7'74- 4<'72..:. Aj"r"r): ~?.Jry ?i..,l;<<:' <br /> <br />.... PI..., f.el frl. to attach a copy of '.at yta,. certlflc.te If avallabll with .ny nscea.,1Y ch.n"....... <br /> <br />Send To (If mailing): <br />OR <br />