Additional Insured Request

ADDITIONAL INSURED REQUEST FORM

Use this form if you need to add a Owners and /or lessors of premises, leased, rented or loaned; sponsors; co-promotors; Designated Persons or Organizations; State or Government Agency or Subdivision or Political Subdivision as additional insured for your event or club liability. All certificates will be emailed to the person submitting the request. If more than 6 are required please submit a second request. Please be sure to enter the date, location, venue address. $20 Per entity
NAME OF CLUB/ORGANIZATION/EVENT HOST*
REQUESTER
What is certificate being requested for?*

CLUB LIABILITY - 20.00UPCOMING EVENT FOR WHICH AN EVENT - 20.00 APPLICATION HAS BEEN SUBMITTEDOther - 20.00
Name & Date of Event*
Purpose of certificate?*
e.g Venue Owner, Municipality, Sponsor, Marina
What date/s is the certificate to be issued for?*
Date/s the certificate will be valid for
Venue Name/Address & Description of Function/Event: *
Eg: Winter Pool Training; ABC YMCA Pool - address
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
EMAIL*
Does the entity need special wording on the certificate or an endorsement? IF YOU HAVE A PERMIT FORM WITH INSURANCE REQUIREMENTS PLEASE UPLOAD A COPY. DO NOT REQUEST AN ENDORSEMENT UNLESS THE ENTITY SPECIFICALLY REQUESTS IT. ENDORSEMENTS ARE NOT ISSUED BY OUR OFFICE THEY ARE ISSUED BY THE INSURANCE CARRIER AND CAN TAKE UP TO 10 BUSINESS DAYS TO RECEIVE. IF NO ENDORSEMENTS ARE REQUIRED YOU WILL RECEIVE AN ADDITIONAL INSURED CERTIFICATE*

CERTIFICATE OF INSURANCE ONLY - NO SPECIAL WORDING/ENDORSEMENTSSPECIAL WORDING ON CERTIFICATEENDORSEMENT/S REQUIRED
Enter Special wording for certificate
PLEASE DO NOT GUESS - ASK ENTITY FOR EXACT WORDING BEFORE SUBMITTING
TYPE OF ENDORSEMENTS REQUESTED - DO NOT CHECK UNLESS YOU ARE SPECIFICALLY ASKED BY THE ENTITY*

CG 20 26 - ADDTIONAL INSURED DESIGNATED PERSON/ORGANIZATIONCG 20 12 - ADDTIONAL INSURED CONTRACTED OWNERS/GOVERNMENT ENTITIESPRIMARY NON-CONTRIBUTORY ENDORSEMENTWAIVER OF SUBROGATION - Blanket Endorsement will be attached30 DAYS NOTICE CANCELLATIONSpecific Wording - Enter specific wording in comments box at the bottom with the name of entity requiring it.
If you have a document from the entity showing requirements please upload a copy of the document

Browse Files
Upload requirements of certificate holder Cancelof
Enter number of ADDITIONAL INSURED CERTIFICATES REQUIRED not total cost - ($20 per entity) *
ADDITIONAL INSURED 1*
ADDITIONAL INSURED 2
NEED MORE CHECK HERE
ADDITIONAL INSURED 3
ADDITIONAL INSURED 4
ADDITIONAL INSURED 5
ADDITIONAL INSURED 6
Total Due ( Pay by check online - no vendor fees. Credit cards are assessed fee by vendor)
COMMENTS -
Once you click Submit you will be directed to the payment window.

IF PAYMENT IS NOT SUBMITTED WITH REQUEST IT WILL NOT BE PROCESSED WITHOUT PRIOR AUTHORIZATION.

Phone: 631-321-6859 or email: paddlesports@jacka-liquori.com
Should be Empty:

ADDITIONAL INSURED REQUEST FORM