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General Liability Certificate of Insurance Request Form
Please fill out all of the following fields.
A copy of the submitted form will be sent to the Swim Club Contact email provided.
If any fields do not apply, please enter "N/A" for that field.
Date of Cert Request:
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+
_____________________________________________________________
Swim Club Information
Swim Club Name:
*Please add your club's name as registered wtih USA Swimming*
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Swim Club Street Address:
*
Swim Club City:
*
Swim Club State:
*
Swim Club Zip:
*
_____________________________________________________________
Swim Club Contact Information
Swim Club Contact (That Completed the Request Form) - Name
*
Swim Club Contact - Phone:
*
Swim Club Contact Email (Certificate will be emailed to this address):
*
Confirm Email:
*
_____________________________________________________________
Certificate Holder Information
Certificate Holder Name: (the entity that you need to send the certificate to)
*
Certificate Holder Mailing Address:
*
Certificate Holder City:
*
Certificate Holder State:
*
Certificate Holder ZIP:
*
Certificate Holder Email Address:
*
_____________________________________________________________
Event Description
Select only the item(s) that the Certificate Holder is requiring the insurance certificate for.
*
USA Swimming Sanctioned competition
Swim practice
Dryland practice
Swim-a-thon (if selecting this, you must have received prior approval for a USA Swimming Swim-A-Thon here: https://www.usaswimming.org/foundation/events-group/swim-a-thon )
Social event/fundraising activity (requires approval)
30-day swim tryout (coverage only if athlete has never been a member, one tryout period per 12 months)
Other (please provide details include whether non-members will be involved)
Other (please provide details include whether non-members will be involved)
Will this event involve team travel?
NOTE: If yes, the USA Swimming
Participant Accident
policy's Covered Activities
include travel to/from a team sponsored event, such as a competition or training camp
. The USA Swimming insurance program
does not include Travel Liability or Auto Liability
. Contact Riskmanagement@usaswimming.org for corporate code for vehicle rentals with Enterprise/National.
*
Yes
No
Travel: Please provide all pool/swimming related activity details for the trip.
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Travel: What are the dates of the trip?
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Travel: How many members are traveling (athletes, coaches, officials)? How many chaperones?
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Travel: Are all chaperones USA Swimming members in good standing? Confirm all Safe Sport MAAPP guidelines and best practices regarding training trips have been/will be followed.
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Travel: Will there be any additional activities (non-swimming) planned for this trip?
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Type of Certificate Requested:
*
Class-1 (Proof of coverage only)
Class-2 (Proof of Coverage and confirmation that the Certificate Holder is an Additional Insured)
Class-3 (Used when the Additional Insured requires specific endorsements, such as Additional Insured form CG 2012 or CG2026, specific Waiver of Subrogation, etc.)
Unsure
_____________________________________________________________
Details of Any Specific Certificate Requests from the Certificate Holder:
_____________________________________________________________
Add a second Certificate Holder to request a second Certificate?
Yes
No
_____________________________________________________________
Certificate Holder Two Information
Certificate Holder Name: (the entity that you need to send the certificate to)
*
Certificate Holder Mailing Address:
*
Certificate Holder City:
*
Certificate Holder State:
*
Certificate Holder ZIP:
*
Certificate Holder Email Address:
*
_____________________________________________________________
Event Description:
*
_____________________________________________________________
Type of Certificate Requested:
*
Class-1 (Proof of coverage only)
Class-2 (Proof of Coverage and confirmation that the Certificate Holder is an Additional Insured)
Class-3 (Used when the Additional Insured requires specific endorsements, such as Additional Insured form CG 2012 or CG2026, specific Waiver of Subrogation, etc.)
Unsure
_____________________________________________________________
Details of Any Specific Certificate Requests from the Certificate Holder:
_____________________________________________________________
Add a third Certificate Holder to request a third Certificate?
Yes
No
_____________________________________________________________
Certificate Holder Three Information
Certificate Holder Name: (the entity that you need to send the certificate to)
*
Certificate Holder Mailing Address:
*
Certificate Holder City:
*
Certificate Holder State:
*
Certificate Holder ZIP:
*
Certificate Holder Email Address:
*
_____________________________________________________________
Event Description:
*
_____________________________________________________________
Type of Certificate Requested:
*
Class-1 (Proof of coverage only)
Class-2 (Proof of Coverage and confirmation that the Certificate Holder is an Additional Insured)
Class-3 (Used when the Additional Insured requires specific endorsements, such as Additional Insured form CG 2012 or CG2026, specific Waiver of Subrogation, etc.)
Unsure
_____________________________________________________________
Details of Any Specific Certificate Requests from the Certificate Holder:
_____________________________________________________________
Add a fourth Certificate Holder to request a fourth Certificate?
Yes
No
_____________________________________________________________
Certificate Holder Four Information
Certificate Holder Name: (the entity that you need to send the certificate to)
*
Certificate Holder Mailing Address:
*
Certificate Holder City:
*
Certificate Holder State:
*
Certificate Holder ZIP:
*
Certificate Holder Email Address:
*
_____________________________________________________________
Event Description:
*
_____________________________________________________________
Type of Certificate Requested:
*
Class-1 (Proof of coverage only)
Class-2 (Proof of Coverage and confirmation that the Certificate Holder is an Additional Insured)
Class-3 (Used when the Additional Insured requires specific endorsements, such as Additional Insured form CG 2012 or CG2026, specific Waiver of Subrogation, etc.)
Unsure
_____________________________________________________________
Details of Any Specific Certificate Requests from the Certificate Holder:
_____________________________________________________________
Upload (one at a time if multiple) a facility use or other agreement(s) provided by the certificate holder(s), if available.
Add any comments regarding the Files attached. Ex. which contract corresponds with which Certificate Holder, if multiple attachments provided.
_____________________________________________________________
This COI request form will be automtically sent to:
IOA Insurance Services
Attn. USAS Service Team
E-mail: USASCOI@ioausa.com
Phone: Paige Montgomery (303) 565-1126