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NYSSRA Nordic COI request
Sanctioned NYSSRA Clubs can request certificates of insurance using this form. Please note that these certificate of Insurance requirements can change from year to year so please confirm this information every year BEFORE you submit this request!
Club name
Your answer
Certificate requested for multiple events?- If yes, describe or attach schedule of events
Your answer
Name of Activity
Your answer
Date of Activity
MM
/
DD
/
YYYY
(Additional dates if applicable)
Your answer
Location (address, city/town), state
Your answer
Name and full address of entity to appear on certificate
Your answer
Entity is
Certificate Requested as:
**If entity is requesting additional Insured, please include the exact Verbiage if any additional language is required by the additional insured. (this is common for government agencies, so please ask before requesting the certificate).
Your answer
Contact Name
Your answer
Contact E-mail Address
Your answer
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