Certificate of Insurance Request
Please complete this form for EACH COI requested. Please be complete with your information. All COI's will be processed with information from this request only. PLEASE ALLOW AT LEAST 1 WEEK FOR PROCESSING.
The COI policy term validity dates are from 3/1/19-3/1/20. Please submit any new Unit Meeting requests by mid- February of each calendar year.
Your Email Address (where COI will be emailed once completed) *
Your answer
Your Name *
Your answer
Contact Phone Number *
Your answer
Date Needed COI by: (Again, please allow at least 1 week for processing) *
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DD
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Unit Type and Number *
Your answer
Date(s) and Time(s) of Event. Please be SPECIFIC. DO NOT USE "BLANKET" DATES. We cannot issue COI's for events without specific dates unless this request is for regular Unit Meetings. *Please notate if this is for your regular unit meetings. *
Your answer
Location Name of Event (Where you are having your event) *
Your answer
If applicable: Inside or Outside of a Retail Location
Your answer
Location Address *
Your answer
Reason for Event (Fundraising, Camp, Regular Unit Meetings, Service Project, etc) *
Your answer
Unit Contact Person/Phone Number (on day of event) *
Your answer
Unit District *
Required
REQUIRED COI Information - IMPORTANT
The person or business requesting the COI from you should give you the following information. Please be as complete and mindful as possible when entering in this information as what you enter is what will be printed on the COI. If you are unsure of any entries below, please contact the person or business requesting the COI from your Unit.
Certificate of Insurance Holder Listing. Please include ALL requested Certificate holders AND address(es). (Address could be different than location address). *
Your answer
Any Additional Insureds (if applicable).
Your answer
Notes or Special Requests
Your answer
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