Insurance update for Dojo and Event Locations

In order to update our files, we would like immediate response to this
request.  Response may be by individual dojo, please distribute this
inquiry immediately.

Please respond by June 26, 2002

The following information should be SENT DIRECTLY TO Tim Yuge (AUSKF
Insurance Coordinator).  Email:  yuge@usc.edu  or  Fax to:  213.740.5737

Use the form below, or this document (Word file or PDF file).

Dojo Name: Member Federation: Dojo Facility(s): Location 1 - Practice or Event* Location?: Name of facility**: Address of facility: City, State, Zip: If applicable: Location 2 - Practice or Event* Location?: Name of facility**: Address of facility: City, State, Zip: *Note: If event, list name of event (tournament, seminar, etc.) and possible dates of use. **If facility requests other additional insured names to be listed on Certificate (eg: School Board, City Council, etc.), please be sure to list those also. Dojo Contact Person: Address: City, State, Zip: Tel: Fax: E-mail:
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