APPLICATION FOR GENERAL LIABILITY INSURANCE

FEB. 15, 2008 through FEB. 15, 2009

GSBF CLUB NAME ______________________________________
PHONE_______________________________

REPRESENTATIVES NAME _________________________________
TITLE _____________________________

ADDRESS   ______________________________________________________

CITY ___________________________ STATE _________ ZIP  ___________

MEETING LOCATION: 
ADDRESS______________________________________________________

CITY ____________________________ STATE _________ ZIP  ___________

How often your club meets ? ________________________________

How many members your club has? __________________________

Are you applying for an Additional Insured Certificate? 
Yes ________ No ________

(If yes, complete the Additional Insured Form for each Certificate)

Make Checks payable to:      GSBF INSURANCE FUND

Mail to: 
Abe Far
2451 Galahad Road
San Diego, CA 92123           

For questions please, phone (619) 234-3434 or E-Mail   AbeFar@cox.net

Postmark deadline for submission of your 2006 application is February 12, 2006.

Fee of $25 applies to each late application (except new members).