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RED HAT INSURANCE PROGRAM APPLICATION 2008

Applications not completed correctly will be RETURNED!
Please print clearly, complete all areas of application and return this completed application
with your cheque for $10 for the administration/application fee no later than February 20, 2008,  to:
   
  Redhatters Insurance, 
    935 Bartholomew Court ,
    Kelowna
, B.C. V1W 4N2

Town/City of Chapter:____________________________________________________        

Chapter name___________________________________________________________

RHS Registration Number_______________________ Number in Chapter ___________

Queen Mothers Name: ___________________________________________________
(i.e. Jane Smith  NOT  Queen Soandso)

Postal Mailing Address: ___________________________________________________  

______________________________________________________________________  

City _____________________________________Postal Code_________________

Email Address:  _________________________________________________________  

Telephone Number:  (________) ___________________________________________  

Submit this application with payment before Feb. 20th. 
We are a registered chapter of the Red Hat Society and would like to apply for
red hat chapter insurance and understand and agree that:

  1. The insurance premium is approx. $10 per person - exact amount to be confirmed with invoice*.
  2. There is an administration fee of $10 per chapter we agree to pay with our application.
  3. Attached is a list of the names of the members of our chapter.
  4. All cheques are to be payable to:        B.C. REDHATTERS
  5. All payments are non-refundable
  6. Enclosed is our cheque for the $10.00 application/administration fee & S&H fee

     AdmininstrationFee:$ 10.00

TOTAL ENCLOSED……………………………………………….  $ ______________________

*Once received you will be issued an invoice with the exact amount of payment due.

__________________________________________  _______________________         
Signature of Queen Mother                                           Date

Office Use only:
Date $ 10 Rec’d ____________________

Chapter Payment Rec’d:________________Amount Paid  $____________________

Cluster # __________________________ Policy #__________________________