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Golfer's Indemnity Application Form  

PROPOSAL FOR GOLFER'S INDEMNITY

  1. Please provide the following contact information:

    First Name
    Last Name
    Street Address
    Address (cont.)
    City
    Zip/Postal Code
    Home Phone
    FAX
    E-mail
    Occupation:
  2. Beneficiary
    Beneficiary Name:
    Beneficiary Address:
    Relationship to the Proposer:
  3. Professional Golfer?
    Please state the name and place of golf club or golf course, where you are a member
    Are you a professional golfer? Yes No
  4. Golf Club Brand(s)

    Please state the number of bags and brand of golf club you own at the time of application (1)

    Golf Club brand (2)

    Golf Club brand (3)
  5. Period
    Period of insurance: From -- mm/dd/yy To: -- mm/dd/yy

To send this form by fax, print this form and fill in the form, thank you.

Proposer's Signature

 ...................................................................

Date

 ...................................................................
 
ICC Tel: 679-8184-91, 679-8689-90 Fax: 285-6427-8

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Revised: 11/03/00