ADDITIONAL INSURED REQUEST

ADDITIONAL INSURED REQUEST FORM

Use this form if you need to add a municipality, landowner, sponsor, etc; 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. The cost to add each entity is $25. Please be sure to enter the date, location, venue address.
NAME OF CLUB/ORGANIZATION/EVENT HOST*
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
EMAIL*
WHAT IS CERTIFICATE BEING REQUESTED FOR*

CLUB LIABILITY -UPCOMING EVENT FOR WHICH AN EVENT APPLICATION HAS BEEN SUBMITTEDOther
Purpose of certifiate*
State the date, exact address/location and purpose of each certificate holder requesting to be added: eg. landowner of venue/marina etc*
NAME THE BODY OF WATER, VENUE AND LOCATION
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 TO5 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 ENTITIESKR-GL-79 - PRIMARY NON-CONTRIBUTORY ENDORSEMENTCG 20 04 - WAIVER OF SUBROGATION/TRANSFER OF RIGHTS30 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
# ADDITIONAL INSUREDS REQUIRED ($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.

Phone: 631-321-6859 or email: paddlesports@jacka-liquori.com
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ADDITIONAL INSURED REQUEST FORM