Certificate of Insurance
This form may be used to request a Certificate of Insurance for your outing, event, or meeting place. Please allow TWO WEEKS for the processing of your request.
Full Name (enter Last, First) *
Your answer
Email *
Your answer
Phone (###-###-####) *
Your answer
Fax Number (###-###-####) *
Your answer
Unit Type *
Unit Number *
Your answer
District *
Brief Description of Activity. This should include the type of event you are holding I.E. picnic, crossover ceremony, fundraising car wash. Be specific. *
Your answer
Date Activity Starts *
MM
/
DD
/
YYYY
Date Activity Ends *
MM
/
DD
/
YYYY
If certificate is for use of a facility, what time will you be using the facility? IE: 4 pm - 7 pm.
Your answer
If certificate is for use of facilities, exactly what part of the facility will you be using?I.E. pavilion and fields, dining hall and kitchen etc. Be specific.
Your answer
Amount Needed for the Certificate *
If over $1 million, please email a copy of the written requirements from the certificate holder.
Requested to be listed as additional insured? *
Any fees required for the services or use of facilities? *
If so, how much?
Your answer
If the facility has given you written specifics with their requirements, please email a copy of that document karen.neiley@scouting.org. All requests for 2M need to have written instructions from the facility emailed or we cannot prepare the certificate.
If this request for a certificate is for a fundraising event other than the Council Popcorn Sale, please email a signed and approved Unit Money Earning Application. Failure to submit an approved Application when requesting a COI for fundraising activities will delay the issuance of the certificate.
Certificate Holder *
The Certificate Holder is the organization who owns the facility where the event or activity is taking place. This cannot be your name and address.
Your answer
Street Address *
No PO Boxes will be accepted.
Your answer
City *
Your answer
State (ie NY, PA) *
Your answer
Zip Code *
Your answer
If certificate is for unit activity, is the holder the chartered organization for the unit involved?
If this certificate is for a Eagle Project, what is the Eagle Scout Candidate's name?
Your answer
Additional comments or information:
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service