Hole In One Insurance Quote Request

Membership Application for Hole -In-One Program

(Selections marked with an asterisk (*) are required.)

Reference No:

Tee Time:

Date of Event:*

Check If New Address:

Contact Name:*

Company:*

Address:*

City:*

State:*

Zip:*

Check If New Phone Number:

Phone:*

Fax:*

Email:*

Prize Sponsor Name:*

Tournament Title:*

Course:*

City:*

State:*

Tournament Director (Name):

Tournament Director (Address):

City:

State:

Zip:

Phone:

Event Information

# Amateurs:*

# Club Pros:*

# Tour Pros:*

Event Type:

# of Players

Total # Shots:

Hole #:*

Yardage/Tee Box:*

Prize Value:*

Prize Description:

EVENT ADD-ONS $100 each

Putting Event - One Amateur Contestant, 50 Feet, $2,500 Cash

Shootout Event - Two Amateur Contestants, 165 Yards, $100,000 Cash