Certificate of Liability Insurance Request
Use this form to request a certificate of liability insurance from Girl Scouts of Southern Arizona. Note that the location/venue requesting the certificate may have specifications (ex: coverage amount, specific verbiage, contact person/department) that should be verified by the person completing this form. Please allow one (1) week processing time.
Your Name:
*
First Name
Last Name
Troop Number (if applicable)
Example: Troop 123
Your Email Address:
*
Would you like to receive a copy of the certificate of liability insurance via email?
YES
NO
Your Phone Number:
*
Please enter a valid phone number.
Name of Location/Venue
*
Ex: Estes Elementary School
Address of Location/Venue
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person at Location/Venue:
*
Include first and last name for the contact person at the location where the certificate will be sent. If not applicable, please indicate N/A.
Email address of contact person at location/venue:
*
The certificate of liability will be sent to the email address provided. If not applicable, please indicate N/A.
Insurance information needs to include a coverage statement. Please select from the options below:
*
The Certificate Holder named below is an Additional Insured on the general liability policy with respect to the use of its premises for Girl Scout activities of the insured Girl Scout Council. (Note: This option should only be selected if the venue indicates it is required. Please verify with location/venue.)
For use of premise for Girl Scout activities of the insured Girl Scout Council. (Note: This is the default statement that should be selected if the location/venue does not request a more specific statement.)
Other
Date certificate is needed by:
*
-
Month
-
Day
Year
Requests must be made at least 1 week in advance.
Is this certificate of liability insurance required as part of a troop trip or high risk activity?
*
Yes
No
Additional information:
Please include any additional information that may be applicable, such as more specific requirements per the location/venue's request.
The information being submitted is correct. Please sign below.
*
Clear
Staff Notes
Submit
Should be Empty: