Certificate of Liability Insurance Request Form

Please fill out this form completely.
You will receive a copy of the Certificate of Liability Insurance via email from Tresa Davis within 1 week of submission.
 

Date Requested

 

Date Required

 

Your Name

 

Email

 

Phone

 

School/Facility:
 

Group using Facility

 

Date of Use

 

# of Students & Staff

 

Name of Facility Requesting Certificate:

 

Street Address

 

City, State, Zip

 

Purpose of Use
 

Send Certificate to:

 

Fax Number

 

Phone Number

 

Company Email

 

Comments or Special Instructions