Certificate of Insurance Request

Certificate of Insurance Request

Please complete this form in order to receive from Girl Scouts of Central Indiana a certificate of insurance for usage of a facility. Please allow at least one week prior to date of usage for the certificate to be processed and sent to the facility.
Name of person requesting certificate:*

First NameLast Name
Troop Number*
Phone Number*

Area CodePhone Number
Email*
Facility Information

All contact information in this section is for the person at the facility you will be using for your event, troop meeting or activity.
Name of facility*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Facility contact person*

First NameLast Name
Phone Number for contact*

Area CodePhone Number
Email for contact to send certificate*
Will you need this certificate again next year?*

YesNo
Reason for use of facility*

Troop meetingService unit meetingOther
If "other" was selected, please use this section to give details.
Date(s) of usage*

School yearSpecific date
Please list specific date of event*
Should be Empty:

Facility Information