Certificate of Insurance Request Step 1 of 5 20% Please carefully review all sections to ensure speedy turnaround with minimal error. Consider every section and complete those pertaining to the nature of your event. Please allow 2-5 regular business days to successfully complete your request. If there are any questions with how to navigate or complete the form, please contact us at [email protected]. Thank you for your dedicated service to the Girl Scouts mission!Requestor Contact InformationName* First Last Phone*Email* Enter Email Confirm Email Position*Troop Leader/Co-LeaderTroop Product SalesOther Troop Team MemberService Unit ManagerService Unit Product SalesOther Service Unit Team MemberStaffOther (non-troop and non-service unit)Please describe:* Troop Number Service Unit125 Journey Girls201 North Journeys; Series202 Southeast Journeys; Series203 Soutwest Journeys; Series400 Rancho Foothills401 Alhambra/Rosemead/SFT402 Bonita403 Claremont404 Anita Oaks/Mission Camellias405 Chino406 Canon Trails407 CV/Glendale408 Pomona409 River Trails411 Upland412 La Canada414 Monrovia/Duarte415 Las Caballeras416 Puente Hills418 San Marino419 Glendora420 South Pasadena421 Covina Oaks422 West Covina425 Crown Poppy426 Mountain View427 Campo Verde428 Ontario/Montclair429 Gateway450 Las Colinas501 Compton/Lynwood502 Bellfower/Hollymount503 Belmont504 Lachen505 Holly Hills507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo517 Southeast518 Center City519 Lawnthornes522 La Brea Heights524 King Harbor526 North Redondo Beach528 Manhattan Beach529 South Bay Four533 Marina538 Palisades/Malibu540 San Pedro542 Santa Monica Bay543 South Torrance544 Torrance545 North Torrance546 PV/Peninsula601 Burbank604 Westside605 Rancho Calabasas606 Las Virgenes608 Palmdale612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Valley641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia645 Summitrose647 Lancaster649 Coyote Canyon650 North RiverUnsure or N/AThis form offers a save and continue feature. If you are unable to complete this form at this time, select "save and continue" and you will be sent a link to return to this form. Event DetailsIs the person in charge of the event the same as the requestor?* Yes No Person responsible for the event:* First Last Purpose of Event*Troop/SU Recurring MeetingSpecial Event/Money Earning ActivityRecruitment EventCookie BoothingProduct DeliveryOtherHave you submitted a Special Event/Money Earning (SEME) application?* Yes No SEME Application Number* Date Meetings Begin* MM slash DD slash YYYY Date of Event/Event Start Date* MM slash DD slash YYYY Event End DateIf applicable. MM slash DD slash YYYY Please describe the event:*Beginning Date of Boothing* MM slash DD slash YYYY End Date of Boothing* MM slash DD slash YYYY Product Delivery Date* MM slash DD slash YYYY Approximately how many people are expected to participate?*Will non-Girl Scout members be participating?* Yes No Has additional insurance been purchased?* Yes No Click here to download the additional activity insurance form. Certificate Holder InformationName of Organization/Location*This is who should be named on the certificate. Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Organization/Location Contact Name* First Last Organization/Location Contact Phone*Organization/Location Contact FaxOrganization/Location Contact Email Enter Email Confirm Email Certificate DetailsHow should the COI be sent to the certificate holder?*This will also apply to any other documents requested. EmailFaxMailOnly to the requestor by emailIt is most common that an evidence-only certificates are sufficient proof of general liability. Additional items are only necessary when specifically requested by the organization/location. Which of the following are required?*Check all that apply. General liability (most common)AutoExcessWorkers CompSexual Abuse/MisconductDoes the certificate holder require an "additional insured" to be named?* Yes No Was the request written or verbal?* Written (Such as a contract or facility use agreement) Verbal Was the verbal agreement made with the organization/location contact as listed above?* Yes No From whom did you receive the verbal request?* First Last How is the additional insured to be named?* Did you request a reciprocal certification of insurance from the certificate holder? Yes No FormsPlease provide any available documentation. Do you have a facility use agreement or other contact? Yes No Facility use agreement or contract*Max. file size: 50 MB.Boothing site permission fom*Max. file size: 50 MB.Reciprocal COI*Max. file size: 50 MB.Do you have additional documents?* Yes No Any additional documents:* Drop files here or Select files Max. file size: 50 MB. Additional InformationPlease provide any comments or additional information we should know.Unique IDCAPTCHA
