Certificate of Insurance (COI) Request
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Is your Chi Alpha group a subcharter of a Chartered ministry? (Please ask your director if you are not sure.)
*
Yes
No
Name of the College/University for your Chartered ministry (the main campus, not the subcharter)
*
Name of the College/University for your Chartered ministry
*
Please provide a reason for why this COI is being requested. Include details such as location, event description, purpose for the request, etc.
*
What is the full name of the organization (university, campground, retreat center, etc) that is requesting this COI from your Chi Alpha group? (Note: This organization will be called the “Certificate Holder” when we make your COI)
*
Mailing address of the organization above
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of the organization above? (in case we need to contact them on your behalf)
*
example@example.com
Does the organization above request that they be listed specifically as "Additional Insured” on the COI? (Please ask them if you are not sure)
*
Please Select
Yes
No
Submit
Should be Empty: