Request Certificate of Insurance

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 date required by the requesting entity. 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 date required by the requesting entity.
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

Date Certificate is Needed By? *

Chapter Contact Information

Chapter Name: *

Chapter Contact: *

Chapter Contact Email: *

Chapter Contact Phone: *

Chapter Contact Alternate Email:

Program/Event Information

Program Start Date: *

Cannot Precede Today's Date

Program End Date: *

Date cannot be later than 11/30/2019

Name of Program/Event: *

This name will be used on the certificate, so please type exact program name (i.e. Paralympic Snowboard Training, The Hartford Ski Spectacular)

Type of Program/Event: *

(i.e. skiing, handcycling, camping, training clinic, fundraising)

Safety Equipment or Precautions: *

Please list all safety equipment (i.e. helmets, lifeguards, personal flotation devices, protective eye wear)

Event Address: *

Additionally Insured-Certificate Holder

Name or Company: *

(Should be listed exactly as required within contract)

Address: *

City: *

State *

Zip: *

Additionally Insured's Relationship to Event: *

(i.e. event site, service provider, sponsor, etc.)

Name of Contact for Additionally Insured:

Please provide name only. No contact information.

Please provide a copy of the contract, agreement, or permit application that states the insurance requirements

Accepted files are .pdf, .doc and .docx. If you have a link to the contract, please insert it in the additional comments box below.

Additional Comments?

Verification *

Please enter any two digit number.

Please only click submit ONCE. Attachments may take 30-60 seconds to upload. Thank you!