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!
On previous insurance policies any land owners or sponsors automatically qualified as additional insureds by definition. Unfortunately, our policy language has changed so there now needs to be an agreement in place ahead of time in order for an entity to qualify as an additional insured on our policy. The following is a flow chart to help you navigate the insurance issues with your event land owners:
1. Is the land owner requesting a certificate of insurance or to be named as an additional insured?
• If NO: Do nothing and you are finished!
2. If YES: The land owner is only requesting proof of insurance, submit a request for a certificate of insurance with your sanctioning package like you have always done on this form. Most times the certificate will just list a property owner or event sponsor. However, some times those entities will require specific language on the certificate. This is especially true when you are dealing with New York State, so please make sure you find out & then tell us exactly what they want to see on it before you submit your request!
3. If Yes, AND the land owner also wants to be named as an additional insured on our policy... Then you will need to have a written agreement between them and NYSSRA Nordic to make that happen. If you have to sign a contract with them that calls for this to happen (Like with O R DA) then you are all set and you just need to give us a copy of that agreement. If they are not requiring you to sign any agreement, then you can print out and use the “NYSSRA-Nordic Event Insurance Agreement” form below and then submit that with your sanctioning package.

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 to be named 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). In this case: You also need to sign and have them sign the agreement a sample is on our website :NYSSRA Nordic request for Certificate of Insurance (page 3)
Your answer
Contact Name *
Your answer
Contact E-mail Address *
Your answer
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