Certificate of Insurance Request
Please fill out all of the fields below to obtain a certificate of insurance (COI). COIs take up to 3 days to process, so please be sure to submit with ample time before it is actually needed. Any field or facility reservations used for practices, games, or events should have a COI on file and name the facility, organization, or renter on the COI. Any questions, please contact Erin at erin@girlsrugbyinc.com.
Girls Rugby State Program
*
Please Select
California
Colorado
Illinois
Kentucky
North Carolina
Ohio
Oregon
Pennsylvania
Washington
Other
Program Staff Full Name
*
First Name
Last Name
Program Staff Email
*
example@example.com
Certificate Information
Certificate Holder - This is the VENUE or ORGANIZATION requesting the COI (i.e. Parks & Rec, Church, etc.)
*
Certificate Holder Contact - Name of the person you've been speaking with
*
First Name
Last Name
Certificate Holder Email - Email of the person you've been speaking with
*
example@example.com
Certificate Holder Address - Address of the organization listed above
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Insured - Please put all information for any additional insured below
Special Instructions - Use this space for any special instructions, as indicated by the Certificate Holder
Date COI is Needed - Please select the first date of the reservation for when you need the COI in hand
*
-
Month
-
Day
Year
Date
Additional Information - Please use this space for any additional information or specifics you need.
Submit
Should be Empty: