Certificate of Liability Request Form

All fields are required:
Sanction Number:
Sponsoring Club:
E-mail address:
Sponsoring Club Address:
Sponsoring Club City:
Sponsoring Club State:
Sponsoring Club Zip:
Sponsoring Club Phone Number:
Sponsoring Club Fax Number:
Third Party Requiring Certificate:
Relationship of Third Party (venue, landlord, etc.):
Third Party Address:
Third Party City:
Third Party State:
Third Party Zip:
Is Third Party to be named an Additional Insured? (yes or no)
Location of Event or Training Facility:
Event Day and Date:
Number of Spectators:
Name of Event (if training facility, write "training"):
Comments: