REQUEST CERTIFICATE OF INSURANCE Order Number First Name * Club Name * Last Name * Email Address * Phone Number * Fax Number * Event Name * Event start date * Event end date * Event time(s) * Event Location * Type of activities club members will participate in: * Demonstration Parade Mall Display Competition Other If you chose 'other' in the field above, please provide details: Are additional Insured(s) required? If yes, an insurance certificate specific to the event will be provided. * Yes No Additional insured legal name(s): Additional insured address: Has the certificate holder specified a limit of liability? * Yes No Limit required is:
