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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
(LSCs requesting a certificate can complete this section as well.)
Swim Club Name:
*Please add your club's name as registered wtih USA Swimming*
*
Swim Club Street Address:
*
Swim Club City:
*
Swim Club State:
*
Swim Club Zip:
*
_____________________________________________________________
Swim Club Contact Information
(LSCs requesting a certificate can complete this section as well.)
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 (for example - swim practice or Sanctioned competition):
**See Note below**
*
**NOTE** Fundraising or social activities must receive written approval to be insured - email RiskManagement@usaswimming.org for approval
Swim-A-Thons must be pre-approved here: https://www.usaswimming.org/foundation/events-group/swim-a-thon
The USA Swimming membership liability insurance program does not include certain coverages, for example: travel liability or automobile liability.
_____________________________________________________________
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