Certificate of Insurance Request

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 coi@girlscoutsla.org.

Thank you for your dedicated service to the Girl Scouts mission!
Requestor Contact Information
Name*
First Last
Phone*
Email*
Enter Email Confirm Email
Position*
Please describe:*
Troop Number
Service Unit
This 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.

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Event Details
Is the person in charge of the event the same as the requestor?*
- Yes
- No
Person responsible for the event:*
First Last
Purpose of Event*
Have you submitted a Special Event/Money Earning (SEME) application?*
- Yes
- No
SEME Application Number*
Date Meetings Begin*
Date of Event/Event Start Date*
Event End Date
If applicable.
Please describe the event:*
Beginning Date of Boothing*
End Date of Boothing*
Product Delivery Date*
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.

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Certificate Details
How should the COI be sent to the certificate holder?*
This will also apply to any other documents requested.
It 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.
Does 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

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