EmailMeForm
Certificate of Insurance Request Form
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.
Date Time
*
MM
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DD
/
YYYY
Name
*
First
Last
Email
*
Confirm
Phone
*
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-
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-
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Fax
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-
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Unit Type
*
Please select
Pack
Troop
Crew
Post
Group
District
Council
Unit Number
*
Brief Description of Activity. this should include the type of event you are holding I.E. picnic, crossover ceremony, fundraising car wash. Be specific. *
*
Date Activity Begins
*
MM
/
DD
/
YYYY
Date Activity Ends
*
MM
/
DD
/
YYYY
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.
If certificate is for use of a facility, what time will you be using the facility?
IE: 4 pm - 7 pm.
Amount Needed for the Certificate *
*
$1 Million
$2 Million
If over $1 million, please email a copy of the written requirements from the certificate holder.
Requested to be listed as additional insured? *
*
Yes
No
Any fees required for the services or use of facilities?
*
Yes
No
if so, how much?
$
Dollars
.
Cents
If the facility has given you written specifics with their requirements, please upload a copy of that document here. All requests for 2M need to have written instructions from the facility uploaded or we cannot prepare the certificate.
If this request for a certificate is for a fundraising event other than the Council Popcorn Sale, please upload 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.
Street Address
*
No PO Boxes will be accepted.
City
*
State
*
Zip Code
*
If certificate is for unit activity, is the holder the chartered organization for the unit involved?
Yes
No
If this certificate is for a Eagle Project, what is the Eagle Scout Candidate's name?
Additional comments or information:
