Request Form For A Certificate Of Liability Insurance

Request for a Certificate of Insurance

If you are holding an event or are performing work and the venue, landowner, or agency has requested a proof of insurance, just fill out the below form and a Certificate of Insurance (COI) will be issued. If you have any questions about this, staff members should contact Samantha Carmichael at samantha.carmichael@tu.org and volunteer leaders should contact Nick Halle at nick.halle@tu.org

I am a*
- Volunteer leader
- TU National staff member
Chapter or council name*

Please include chapter or council number. If you are TU National staff, please enter “Trout Unlimited, Inc”.
Chapter or council point of contact name*
Point of contact volunteer role*
Address*
City State / ZIP Code –
Phone*
Email*
Event name*
Event type
Other event type
Event description
Please provide a brief description of your event
Event start date
MM slash DD slash YYYY
Event end date
MM slash DD slash YYYY
Event dates
Certificate holder

The person, facility, state, county, etc. who is requesting proof of liability
Certificate Holder Address*
City State / ZIP Code –
Name of contact at certificate holder venue*
Certificate holder email address*
Event location
- This event will occur at a location that is different from the Certificate Holder address listed above.
Address
Street Address Address Line 2 City State ZIP / Postal Code
This certificate needs to be faxed
- This certificate needs to be faxed
Fax number of certificate holder venue
Other venue requirements
Equipment will be rented or leased for this event
- Equipment will be rented or leased for this event
Is your chapter/council leasing this piece of equipment? And if so, is the lease in your chapter/council name?
Is your chapter/council leasing this piece of equipment? And if so, is the lease in your chapter/council name?
Does this project have a name?
What are the dates of the project?
Who will be operating the equipment and what is their experience?
Did the chapter purchase the insurance offered by the leasing company, or do they expect the coverage provided by TU's policy?
If so, we will need to add the piece of equipment to the policy and there will be a charge associated with it. We will also need to know what the value of the equipment is and when are you leasing it (include specific dates)
To whom should the invoice be sent?
Serial numbers of leased equipment, if available
Does the leasing company need to be added as loss payee and additional insured for the leased equipment?
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Request Form for a Certificate of Liability Insurance

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Request for a Certificate of Insurance

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