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.
 +
_____________________________________________________________
Swim Club Information
_____________________________________________________________
Swim Club Contact Information
_____________________________________________________________
Certificate Holder Information
_____________________________________________________________
Event Description *
 
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. *
Type of Certificate Requested: *
_____________________________________________________________
_____________________________________________________________
Add a second Certificate Holder to request a second Certificate?
_____________________________________________________________
Certificate Holder Two Information
_____________________________________________________________
_____________________________________________________________
Type of Certificate Requested: *
_____________________________________________________________
_____________________________________________________________
Add a third Certificate Holder to request a third Certificate?
_____________________________________________________________
Certificate Holder Three Information
_____________________________________________________________
_____________________________________________________________
Type of Certificate Requested: *
_____________________________________________________________
_____________________________________________________________
Add a fourth Certificate Holder to request a fourth Certificate?
_____________________________________________________________
Certificate Holder Four Information
_____________________________________________________________
_____________________________________________________________
Type of Certificate Requested: *
_____________________________________________________________
_____________________________________________________________

_____________________________________________________________
                                                     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