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Insurance Request Form
THE STANDARD INSURANCE REQUEST MAY TAKE UP TO 5 WORKING DAYS.
THE EXTRA INSURANCE REQUEST (OVER 1M) MAY TAKE UP TO 10 DAYS.
** REQUESTS ARE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED **

* Full Name
* Contact Email Address
* What type of event is this?
* District
* Description of Activity
* Activity Date(s)
If certificate is for use of facilities, please describe
* What amount of Insurance is needed
If over 1 million dollars a copy of written requirements from the certificate holder is required
1,000,000 over 1,000,000

Please email any completed contract, permit or application from the certificate holder indicating their insurance requirements. 

Send the email to Amy Davidson

* Complete name and address of requesting organization of this certificate
* Has the requester asked to be listed as an additional insured?
Yes No
* Are there any fees required for services, use of property, etc.?
Yes No
* If the certificate is for a unit activity, is the certificate holder the charter organization for the unit involved?
Yes No
Any additional comments

THE STANDARD INSURANCE REQUEST MAY TAKE UP TO 5 WORKING DAYS.
THE EXTRA INSURANCE REQUEST (OVER 1M) MAY TAKE UP TO 10 DAYS.
** REQUESTS ARE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED **
5/22/2015



Copyright Cradle of Liberty 2015

Copyright Cradle of Liberty 2015