Certificate of Insurance Request Form

First Name *

Last Name *

Phone Number *

Email Address *

District *

Unit Type *

Unit Number *

Date of Activity * +

Insurance Information

Amount *

$1,000,000

$2,000,000

Additional Insured? *

Yes

No

Description of Activity *

Location of Activity *

Certificate holder is the organization/business requesting a certificate of insurance for the use of their facility or property.

Organization/Business Name *

Holder Street Address *

Holder Address Line 2

Holder City *

Holder State *

Holder Zip Code *

Please fill this form out completely and submit. If you have any questions please contact Karen Wanek at Karen.Wanek@scouting.org or P: 630-797-4609