Girl Scouts of Western Ohio | Request for Certificate of Insurance

Certificates of Insurance (COI) are issued with active dates based on the insurance plan year, which runs October 1st through September 30th (just like the Girl Scout membership year.) COI for the upcoming year cannot be issued by the insurance company until the end of September.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Home Region
Facility Information
Name of Facility
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Activity

MonthDayYear
Date
Type of Activity
Facility Contact Information
Facility Contact Name

First NameLast Name
Facility Contact Phone Number
Please enter a valid phone number.
Facility Contact Fax Number
Please enter a valid fax number.
Facility Contact Email
example@example.com
Please verify that you are human*
Should be Empty:

Facility Information