Certificate of Insurance Request Form

Civitan International Certificate of Insurance

All requests by outside parties for proof of a Certificate of Insurance (COI) are to be directed to Civitan International. Requests are subject to approval and should be made prior to promoting the event or before making commitments to the outside party.

Club Requesting Certificate of Insurance (COI)(Required)

Contact Info for Insured Club/Region Member Requesting Certificate

Name and Title(Required)

Club/ Region Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Contact Info for the Entity Requesting COI

Name of Entity Requesting to be named Certificate Holder(Required)

Mailing Address of Certificate Holder(Required)

Certificate Holder City, State, Zip(Required)

Phone Number of Certificate Holder(Required)

Date COI is Required(Required)

Detailed Description of Event, Activity, or Reason for which a COI is being required.(Required)

Upload any contracts or agreements for this event (whether official contracts or implied agreements via email). Also, include any specific outlining requirements for the COI.

Max. file size: 512 MB.