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.
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 *
Contact Name
Phone *
Fax Number
Fax Number
Mailing Address *
Mailing Address