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 Unit400 Rancho Foothills401 Alhambra/Rosemead/Santa Fe Trails402 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 Mt. View427 Campo Verde428 Ontario/Montclair429 Gateway450 Chino Hills501 Compton/Lynwood502 Bellflower/Hollymount503 Belmont504 Lachen505 Holly Hills506 Highland Rose507 Lakewood508 Alamitos/Marina509 Westchester/Del Rey511 Culver City512 RDE/Sil-Dom513 Northeast Hills515 El Segundo516 East LA517 Southwest SU518 Center City519 Lawthornes522 La Brea Heights524 King Harbor526 North Redondo528 Manhattan Beach529 South Bay Four533 Marina538 Pali/Mali540 San Pedro542 Santa Monica Bay543 S. Torrance545 Torrance546 PV/Penn601 Burbank604 Westside605 Rancho Calabasas606 Las Virgenes608 Palmdale/Acton/Agua Dulce612 Golden Savannahs616 Canyon Star617 Sagebrush624 Woodland Hills636 Kern640 Mission Rose641 Twin Oaks642 Heart of the Valley643 Stoneyridge644 Magnolia649 Coyote Canyon650 North RiverThis 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
