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MICHIGAN SOCCER ASSOCIATION
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 Member of the United States Adult Soccer Association
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 867 South Boulevard ~ Pontiac, MI 48341 ~ (586) 924-2400
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 2025 CERTIFICATE OF INSURANCE REQUEST FORM
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Use "TAB" to move to next field to enter information.
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LEAGUE NAME
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Mailing Address
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City ZIP
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League Contact Person Telephone
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E-Mail
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TEAM NAME
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Contact Person
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FACILITY OWNER
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Mailing Address
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City ZIP
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Contact Person Telephone
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E-Mail
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FACILITY NAME
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Address
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City ZIP
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Requests for Certificates of Insurance (field insurance)
will only be accepted when submitted by the League Administrator to:
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Michigan Soccer Association at
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MiSoccerAssoc@hotmail.com
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Questions, please contact Dyann Pugliese at (586) 924-2400.
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