Request for Certificate of Insurance
Please include the following information in your request:
Name of Certificate Holder:
Full Name of Facility
Mailing Address of Certificate Holder:
Facility
Email address or fax number of Certificate Holder:
*
Insurance Requirements of Certificate Holder:
*
(if any – such as wanting to be named as an additional insured on the general liability policy for LLL):
Name and Complete Address of Event Location:
Type of Event
Series Meeting
Conference
World Breastfeeding Month event
Fundraiser
Other
Date & Time of Event
(repeated meeting date, e.g. the 3rd Thursday of the month, OR specific event date):
Who is Requesting This Certificate?
LLL Group
Area
Area Network:
La Leche League Alliance
Leader Name
Leader Email
Submit
Should be Empty: