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   E.D.G.E. & T.A.

Early Day Gas Engine & Tractor Association

 

Proof of Insurance Certificate/

Additional Insured Certificate

1.  If a Land/Facility Owner requests a "Proof of Insurance" for a Branch Event, fill out the form below and submit.  The Certificate will be sent directly to the Land/Facility owner requesting the "Proof of Insurance Certificate". 

2.  If the Land/Facility Owner requires to be added as an "Additional Insured", check the "Additional Insured Certificate" box and fill out the form below and submit.  The "Additional Insured Certificate" will be sent directly to the Land/Facility owner requesting the "Additional Insured Certificate".

Please submit both of these requests 30 days (not less than 10 days) prior to the date the certificate is needed by the landowner.  The insurance agent needs time to process these requests.  Requests made at the last minute may not be able to be processed by the time you need it!  (see question 19 on the Q & A).

 

Do need an "Additional Insured Certificate"? 

(Note:  If you choose yes, the Land/Facility Owner automatically gets both certificates.)

 

Do you need a "Proof of Insurance Certificate"?  

If you need both, check yes for both places.  Information is the same for both requests.

(In the future, the insurance carrier will not send out an insurance certificate at the beginning of the insurance year, April/May, as they have in the past.)  These certificates will be sent directly to the party requesting the coverage.

Branch #: 

Contact Name:                      E-Mail Address:  

Address:       City:     State: 

Zip Code:               Phone Number:              Fax Number:   

This is Needed No Later Than -mm/dd/yyyy: 

Event Name: 

Event Held From -mm/dd/yyyy:   to -mm/dd/yyyy:

Address Where Event Will Be Held:

Address:       City:     State: 

Certificate Holder Information

Land/Facility Owners Mailing Address and Fax Number:

Contact Name:                      Attention:  

Address:       City:     State: 

Zip Code:                      Fax Number:   

Please include any specific wording required by your contact with the land/facility owner:

Please review the form to ensure all of the information is filled in and is correct, then press submit.

    

   
To send by Postal Mail, send to:  

Rich and Cartmill, Inc.

Jennifer Smith

4945 N. Towne Centre Dr.

Ozark, MO  65721

(417) 581-4003 Phone

(417) 581-4045 Fax

 

If you have any questions regarding our insurance, such as information on Insurance coverage, requests and photos for people mover approval, information on insurance non-coverage related questions, such as form submittal problems, or if you have problems resolving a problem with our insurance agent, contact: 

 

Dick Tombrink

2250 North 12th Road

Worden, MT  59088

(406) 967-6687 Voice

(406) 967-6687 Fax

E-Mail:  dicknsue@nemontel.net

 

Larry Voris

2340 S Luster

Springfield, MO  65804

(417) 882-7195 Voice

 

E-Mail:  lgvoris@sbcglobal.net

 

 

For all requests for Proof of Insurance Certificates/Additional Insured Certificates, fill out and submit the form on the web page under Insurance Info.  A copy will go to the insurance agent, and Dick Tombrink.

 

For your information if you wish to fax it, below is the insurance agent's name and fax number.  They will not accept information by phone for your requests.

 

Rich and Cartmill, Inc.

Jennifer Smith

4945 N. Towne Centre Dr.

Ozark, MO  65721

(417) 581-4003 Phone

(417) 581-4045 Fax

jsmith@rcins.com

tgraesser@rcins.com

 

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