REQUEST FOR CERTIFICATE OF LIABILITY INSURANCE

Certificates of insurance are issued upon request to companies and/or organizations providing the use of their site to Girl Scout troops/groups for Girl Scout activities. Many organizations/companies require a certificate of insurance before they will allow a group to reserve their site. Certificates of insurance must be requested for each site. We do not have one blank certificate to send out. Please submit your request for a certificate of insurance 2-4 weeks prior to the scheduled use date. The certificate will be prepared and faxed directly to the insured organization/company. Certificates of insurance are good from October 1 to October 1 of the following year. Schools are covered under the District and certificates are mailed to the District Office. We do not cover each school individually. Please refer school requests to their District Office. If requesting a certificate for a school, please indicate the School District and that mailing address instead of the school. Certificates provide $1,000,000 General Liability Coverage. Certificates provide $1,000,000 General Liability Coverage. Please allow 1-2 weeks for processing.

Type of event/program*

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Company/Organization Name*

Address_Line1*

Address_Line2

Address_City*

Address_State*

Address_PostalCode*

Email*

Phone*

Send to the attention of:*

Other affiliates to be listed as additional insured:

Person Requesting Certificate

Name_First*

Name_Last*

Person Requesting Email*

Phone2*

Will this require automatic yearly renewal?*

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Girl Scout Activity/Event Start Date

Dates not required for troop meeting locations.

Girl Scout Activity/Event End Date

Dates not required for troop meeting locations.

If you have any Questions, please contact GSACPC at: 602.452.7000

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