Trek Insurance

The Coalition of Historical Trekkers
Event Insurance Application Form

Complete this form and Submit or print out the printable version and mail to
Tod Wells
2135 28th Ave. West
Brookings SD 57006

* Indicates required field

Event Name *

Event Date *

Event Duration *

Event Address City/State/Zip *

Proposed Number Attending *

Type Of Land *

Private Public

Type Of Event Being Held *

Live Fire/Amunition *

Yes No

Your Name *

First

Last

Your Address/Phone *

Line 1

Line 2

City

State

Zip Code

Country

Your Email *

Submit