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Certificate of Insurance Request
All requests are due two weeks prior to the event
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* Indicates required question
Unit Type
*
Pack
Troop
Crew
Post
Unit Number
*
Your answer
District
*
Hockanum River
Mad River
Mark Twain
Matianuck
Mattabesett Trail
Mohegan
Nipmuck
Northwest Hills
Exploring
Scoutreach
Unknown
Information About Certificate Holder
This information is about the organization that the certificate is going to.
Name of Organization
*
Your answer
Organization's Street Address
*
Your answer
Organization's City, State, Zip
*
Your answer
Organization's Phone Number
*
Your answer
Organization's Email
Your answer
Select Amount of Insurance Request
*
$1,000,000
$2,000,000
Does the Organization Wish To Be Listed As "Additionally Insured"
*
Yes
No
What is the date(s) of the event?
Your answer
Name of Event
*
Your answer
Name of Facility Being Used (ex: School ,Church & what Part of Building)
*
Your answer
Physical Address of Facility Being Used
*
Your answer
BSA Unit Contact Information
First Name
*
Your answer
Last Name
*
Your answer
Phone Number (Home)
*
Your answer
Phone Number (Work)
Your answer
Email Address
*
Your answer
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