Type of Certificate:

Option 1: This form is used to show proof of insurance. No additional insured is needed.

Option 2: This form is used to show proof of insurance and to add additional insured's for use of their premises.

Option 3: This form is used to show proof of insurance and to add additional insured's - State or Political Subdivision - for issuance of permits

Event Name & Date(s):

Requester Phone Number:

NOTE: Your phone number will NOT appear on the certificate.

Your Club/District:

Name:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Certificate Holder: This is the individual/entity to whom you are providing the certificate.

Name:

Address:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zipcode:

Please Enter This Security Code Below:

You must enter code to Submit this form: