General Liability Certificate of Insurance Request Form

2023-2024 Renewal Certificates

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.

**If your club is in need of more than four renewal certificates, please send your request directly to USASCOI@ioausa.com and include the name and state of your club and the names of all facilities needing a renewal certificate.

Date of Cert Request: * +

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Swim Club Information

Swim Club Name:
*Please add your club's full legal name* *

Swim Club City: *

Swim Club State: *

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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: *

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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: *

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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