Certificate of Insurance Request Form

Requester First Name

*

Requester Last Name

*

Requester E-mail

*

Service Unit or Troop Number

*

SU/Troop E-mail

Activity Name

Activity Date(s)

*

Name of Facility Requesting GSEP Certificate

*

Address of Facility

*

Contact Name at Facility

*

Facility Contact E-mail

*

Facility Contact Fax Number

*

Additional Insureds (if required by facility)

Special Wording/Instructions

WebTemp_JOIN_Lead-like-a-GirlScout_170x240

WebTemp_JOIN_Lead-like-a-GirlScout_170x240

WebTemp_VOLUNTEER_HelpHerShine_170x240

WebTemp_VOLUNTEER_HelpHerShine_170x240