Super Series

Certificate of Insurance Request Form for Additional Insured

Enter the Super Series Team#

Team Name

Your Name

Your Email

Additional Insured Name

Additional Insured Address

Additional Insured City

Additional Insured State

Additional Insured Zip

Email address for Certificate delivery

Field Location

Sponsor

Fax Number

Please contact Sevlija Korkutovic with any questions at ksevlija@bene-marc.com
or call (817) 738-6899 ext.313.

Bene-Marc, Inc.
6301 Southwest Blvd, Suite 101 Fort Worth, Texas 76132-1063
800-247-1734 or 817-738-6899