Request for Certificate of Insurance
This form is only utilized when a facility/organization requires a certificate of insurance.

Named Insured:
Facility Address:
Street:
City:
State:
ZIP:
Date of request:
Date certificate
needed by:
Name of person
completing form:
Name of Company:
Phone: -
Fax: -
E-mail:
Coverage Needed:
General Liability
Automobile Liability
Workers’ Compensation
Property $
Excess/Umbrella $
(Please indicate amounts needed for property and excess/umbrella.)
Other:


If this is a request for an EVENT please complete this section,
if not skip to number 5.

1.Name of event:
2.Date(s) of event:
3.Site or location
of event:
4.Is the insured the primary host for the event?:Yes   No   


5.Certificate Holder:
6.Certificate Holder address:
7.Certificate Holder Phone: -
Fax: -
E-mail:
8.Contact Person:


9.Does the Certificate Holder require additional insured* status?:
Yes   No   
If yes, please specify Additional Insured wording:

*Additional insured should only be checked if it is a requirement of the Certificate Holder.
10.If number 9 has been checked, please outline the role
the Additional Insured is playing in the activity
(i.e. landowner, municipality, corporate sponsor, etc.):
11.Have you entered into any agreement, contract or permit that contains Assumption of Liability, Indemnification or Hold Harmless language?:
Yes   No   
(If yes, please forward a copy of document with this request.)
12.Original certificate should be sent to:
Certificate Holder
Named Insured
Monument Sports
Person Completing Form

If printed, please forward completed request to:
THE MONUMENT SPORTS GROUP
508 NORTH ALLISON AVENUE, #1
RICHMOND, VA 23220-2704
PHONE: 804-354-9020
FAX: 804-354-9022

The Monument Sports Group manages your insurance needs so that you can concentrate on growing your business.
Copyright © Monument Sports Group, 2003