Surveys and Forms

Certificate of Insurance Request Form
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* Please select todays Date?
* Name
* Email Address
* Phone Number No dashes or spaces, just the 10 digits.
Return Fax Number Numbers only, no dashes
* Unit Type
* Unit Number
* District What is the District that you belong to?
* Unit, District or Council Activity
* Brief Description of Activity:
Date(s) of Activities Example: 4/22/05-4/24/05
If certificate is for use of facilities, describe:
* Amount Needed for the C of I If over $1 million, please email a copy of the written requirements from the ceriticate holder.
$1 Million $ 2 Million
* *Certificate Holder (Complete Name and Address of Place Requesting Insurance)
* Has the certificate holder requested to be listed as additional insured?
* Are any fees required for services, use of property, etc? If yes please answer the next question.
If so, amount being charged?
* If certificate is for a unit activity, is the certificate holder the chartered organization for the unit involved?
Additional comments:
*Please allow at least TWO WEEKS for processing of certificate requests. REQUESTS ARE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED!