Club/chapter liability insurance application

Club Information

Are you a current IMBA Club/Chapter?

IMBA affiliation IS NOT a requirement, however, IMBA Clubs/Chapter receive special member pricing discounts.

Yes, we are an active IMBA Club/Chapter

No, we are not affiliated with IMBA

Full Legal Name of Organization

Note: This is the name that will appear on your Certificate of Insurance. If your company is a Sole Proprietorship, then this will be your personal name of DBA.

Contact Name

First Name

Last Name

Phone

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Email

Fax Number

(###)

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Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country