"Request for Certificate of Insurance - Boy Scouts of America"

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REQUEST FOR CERTIFICATE OF INSURANCE
(Please print legibly or type- Fields in BOLD must be completed or certificate cannot be issued.)
For “Proof of Insurance” Only fill out questions 1-11 completely.
Date: ____________________
1. Requester Name ________________________________ Email address __________________________________or
2. Fax __________________________________________ Phone_______________________________ext. _______
3. Unit # or District Name __________________________ Field Service Council ______________________________
4. Description of activity ____________________________________________________________________________
5. Location of Activity (name and address) ____________________________________________________________
6. Date(s) of activity ________________________________If certificate is for use of facilities, describe____________
__________________________________________________________________________________________________
7. Insurance amount needed $____________________ (if known)
8. Certificate Holder (name, address, city, zip) business, group, or organization to be insured___________________
__________________________________________________________________________________________________
9. Phone_________________ext. _______ Fax ____________________ or E-mail ______________________________
10. Are any fees required for services, use of property, etc?
Yes
No
Amount _______________
11. If certificate is for a unit activity, is the certificate holder the chartered organization for the unit?
Yes
No
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
For request by business, group or organization to be “Additional Insured”, complete 1-10 above and 11-12 below.
If over $1 million, please attach a copy of the written requirements from the certificate holder.
11. Certificate holder (complete name, address, city, zip)
12. For additional insured certificates, please put in exact verbiage that is to be put on certificate here.
Additional comments
For Cub Scout Day Camps:
a. Attach a copy of lease agreement/contract, specifically the pages that include indemnity language and insurance requirements.
b. Scout executive confirmation that the camp program will be conducted in accordance with established standards as set in National Standards for
BSA Local Council Accreditation of Cub Scout / Webelos Scout Day Camps N. 13-108, and that the day camp director and program director hold
current training certification through the National Camping School.
Scout Executive Initials _________
Send to
tom.oleniacz@scouting.org
Please allow at least two weeks for processing of certificate requests.
Requests are processed in the order in which they are received.
REQUEST FOR CERTIFICATE OF INSURANCE
(Please print legibly or type- Fields in BOLD must be completed or certificate cannot be issued.)
For “Proof of Insurance” Only fill out questions 1-11 completely.
Date: ____________________
1. Requester Name ________________________________ Email address __________________________________or
2. Fax __________________________________________ Phone_______________________________ext. _______
3. Unit # or District Name __________________________ Field Service Council ______________________________
4. Description of activity ____________________________________________________________________________
5. Location of Activity (name and address) ____________________________________________________________
6. Date(s) of activity ________________________________If certificate is for use of facilities, describe____________
__________________________________________________________________________________________________
7. Insurance amount needed $____________________ (if known)
8. Certificate Holder (name, address, city, zip) business, group, or organization to be insured___________________
__________________________________________________________________________________________________
9. Phone_________________ext. _______ Fax ____________________ or E-mail ______________________________
10. Are any fees required for services, use of property, etc?
Yes
No
Amount _______________
11. If certificate is for a unit activity, is the certificate holder the chartered organization for the unit?
Yes
No
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
For request by business, group or organization to be “Additional Insured”, complete 1-10 above and 11-12 below.
If over $1 million, please attach a copy of the written requirements from the certificate holder.
11. Certificate holder (complete name, address, city, zip)
12. For additional insured certificates, please put in exact verbiage that is to be put on certificate here.
Additional comments
For Cub Scout Day Camps:
a. Attach a copy of lease agreement/contract, specifically the pages that include indemnity language and insurance requirements.
b. Scout executive confirmation that the camp program will be conducted in accordance with established standards as set in National Standards for
BSA Local Council Accreditation of Cub Scout / Webelos Scout Day Camps N. 13-108, and that the day camp director and program director hold
current training certification through the National Camping School.
Scout Executive Initials _________
Send to
tom.oleniacz@scouting.org
Please allow at least two weeks for processing of certificate requests.
Requests are processed in the order in which they are received.