PLEASE SCROLL DOWN TO COMPLETE CERTIFICATE OF INSURANCE FORM

An entity or an individual such as a property owner, sponsor, service provider or event partner may contractually require that they be named as an additional insured and provided with a certificate of additional insurance. To request an additional insured certificate for the policies that your chapter carries through Disabled Sports USA Group Insurance Program, please fill out the form below.

Before entering into any contract with an outside party, please review the insurance requirements and verify that your chapter’s insurance coverage meets them. If you have questions about whether or not the policies held through the Disabled Sports USA Insurance Program will cover the requirements, please contact Cheryl Collins (ccollins@dsusa.org or 301.217.9841) before agreeing to the contract terms.

Below are instructions to ensure your Request for Certificate of Insurance is processed properly:

  • Submit the request for certificate of insurance AT LEAST 10 BUSINESS DAYS PRIOR to the event needing coverage. This will ensure the paperwork has enough time to be processed. DSUSA cannot guarantee certificates for requests that are not submitted 10 business days prior to the coverage start date.
  • Fill out all required information within the form
  • Attach the contract/agreement/permit application that states the specific insurance requirements or provide a link to the document.

View a Sample Certificate of Insurance Form

Request for Certificate of Insurance

Chapter Contact Information

Program/Event Information

Cannot Precede Today's Date
Date cannot be later than 11/30/2018
This name will be used on the certificate, so please type exact program name (i.e. Paralympic Snowboard Training, The Hartford Ski Spectacular)
(i.e. skiing, handcycling, camping, training clinic, fundraising)
Please list all safety equipment (i.e. helmets, lifeguards, personal flotation devices, protective eye wear)

Additionally Insured-Certificate Holder

(Should be listed exactly as required within contract)
(i.e. event site, service provider, sponsor, etc.)
Please provide name only. No contact information.
Accepted files are .pdf, .doc and .docx. If you have a link to the contract, please insert it in the additional comments box below.
Please enter any two digit number.