CERTIFICATE OF INSURANCE REQUEST FORM

CERTIFICATE OF INSURANCE REQUEST FORM

Dec. 1, 2024 to Dec. 1, 2025
Contact Kirsti Kontor - kirsti@swimontario.com
BFL CANADA WILL ISSUE THE CERTIFICATE ONCE THIS REQUEST FORM IS RECEIVED BY YOUR PROVINCIAL ASSOCIATION
This is to certify to: (Name of entity requesting proof of insurance)*
Address*
Full address - All on one line
that the following described policy(ies) or binder(s) in force at this date have been effected to cover as shown below

Name of Insured:
SWIMMING / NATATION CANADA
307 Gilmour Street, Ottawa, Ontario K2P 0P7
and:
SWIM ONTARIO
875 Morningside Ave, Toronto, ON M1C 0C7

and:
Name of Team/Club Assoc.*
Name of Contact*
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Website Address
Description of Event(s)*
Location*
Date(s)*
ADDITIONAL INSURED (LEGAL NAME)

IF ADDITIONAL LIST ATTACHED, PLEASE CHECK
Additional Insured #1.
Additional Insured #2.
Additional Insured #3.
Additional Insured #4.
Additional Insured #5.
Additional Insured #6.
Additional Insured List*

Cancelof
THE ABOVE ENTITIES WILL BE ADDED TO THE POLICY AS ADDITIONAL INSURED BUT ONLY WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED DESCRIBED ABOVE. THE CERTIFICATE APPLIES TO THE MEMBERS AND AUTHORIZED PERSONNEL OF THE INSURED WHILE OPERATING WITHIN THE SCOPE OF THEIR DUTIES AND APPLIES ONLY TO THE DATES OF THE EVENT AS MENTIONED ABOVE.
Applicant Name*

First NameLast Name
Applicant email address*
example@example.com
Should be Empty: