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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:
*
+
_____________________________________________________________
Swim Club Information
Swim Club Name:
*Please add your club's full legal name*
*
Swim Club Street Address:
*
Swim Club City:
*
Swim Club State:
*
Swim Club Zip:
*
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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:
*
_____________________________________________________________
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:
*
_____________________________________________________________
Please upload a copy of the facility use or other agreement provided by the certificate holder, if available.
_____________________________________________________________
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