Certificate of Insurance Request
All requests are due two weeks prior to the event
Unit Type *
Unit Number *
Your answer
District *
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 *
Does the Organization Wish To Be Listed As "Additionally Insured" *
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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