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<br />JAN 26 2004 13:13 FR ARTESYN ENGINEERING 612 392 6740 TO 96514298629 <br />02/08/02 l'RI 10: 32 fAX TJ ADAIUl GROUP <br />. TJ ~~AM~'I~~9B~ <br /> <br />P.08/11 <br /> <br />lllIoaa <br /> <br />REQUEST FOR VONS CERT/F/CA TES OF INSURANCE <br />.....NOTE: WE REQUIRI! lBUSINES-.pAVS TO PROCESS THIS R.QUE.T...... <br />Dete , - .2.b - rA <br />Thll form cln either be faxed or man.d to T. J. Adami Group, LLC <br /> <br />" <br /> <br />Add,...: 333 E. Butterfi.ld Rd., ata. 100 <br />Lomblrcl,'lL 80148 <br />Attn: Marel R'y" <br /> <br />CLUB INFORMATION: <br /> <br />FUt: (130)3244781 <br />Attn: Marcl Ray.. <br /> <br />Name of Llonl Club <br /> <br />.e:::.ll<'-""'I3i2.VIL-l-\2" L-tC>,-J> ,/ L.--Ui} <br /> <br />Addre" <br /> <br />P"J I r,; q '302...''-l ~\"t <br /> <br />City, Stato, Zip /" .:?~l4J,c..<...4" ,1M_I c:;? D>;'S <br />EVENT INFORMATION: <br /> <br />Ev.nt ;z...c.o4'1 R.....-r~ ~;. /.-.I'IL.--j. -/ L:...-IT-I Re1:ff""Il/A<- <br /> <br />t(l) of Event <br /> <br />AtJb-\J~l (.., "7 .... B 2-Po4- <br />. . <br /> <br />Loc.llon of Event L-A""~ ~~ ~G;..Jn:w..vl~ JIr.~ P'::L- Tie;2 L-.l'ri-.::> <br />, <br /> <br />CERTIFICATE HOLDERJADDITIONAL INSURED INFORMATION: <br /> <br />?l"l1 Di::=- /..J.~V!4I~ <br />-' f:,g (> 'l'^J>rl . 4~~ I <br />/ ~.':2."...' -::- ,....~ c:;r;D'31> <br />. <br />J,.t:;""l - 4.-2 q - "3>~ ~2- <br /> <br />Acldlllona! Inlured.: (In ord.rto be an addlClon.1 inaurld, tha p.rty mUltoWII tha pramJ"1 on whleh ~ou <br />are Clonduetlnllll.!!ur lvent tt.~. public bur I..ulng . P'!:!!!"): <br />U NQnl I.2KSsme 88 Certificate Holder LJ Owr.rent flom Cert. Holder <br /> <br />C.rtIflc.tl Holder: <br />(party raq\llrlnll <br />certlfi~le from <br />your club) <br /> <br />MAILING/FAX INFORMATION: <br /> <br />Requ..ted By: ~ ?"'~ ~1t:'>"'......+z,iZS"I <br />Phone'" where you csn be ,eachad for queetlona: 1-,,12-.- 2-2 \ -<:J, 2--2... <br /> <br />~&. ILI""~~? I <br />~? i3ia-~ 1'"'= I v.. <br />C~\II\.--""'~' ""'-.} e;C;o'3>S <br />-rg(FaxNumblr: b$I-A-i'--'9-~29 Am...i..~~~ 13€.....~;:~" <br /> <br />.... PI...e tl.1 f.... to attac" a copy of 'lit y.ara ,,,rtlflcatalf IVlllabl. with any n.e....ty chInQ....... <br /> <br />""';Send To (If mailing): <br />OR <br />