Request Certificate of Insurance - Disabled Sports USA

Request Certificate of Insurance

Incident Reporting

Request Certificate of Insurance

DSUSA Administrative Policies

Risk Management Resources

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 Ryan Semke (rsemke@dsusa.org or 240.268.5370) 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.

Click Here for the Basics of Certificates of Insurance Webinar

View a Sample Certificate of Insurance Form

Request Certificate of Insurance

The "Save & Continue Later" function can be found at the bottom of this report form. If selected, a pop-up notice will provide a unique URL which will allow you to access the form at a later time. The URL will also be sent via email to the Primary Contact listed. Please note before using this feature: DSUSA cannot access partially completed forms or the URLs associated with the forms. Not all browsers work with this feature. We recommend that you test the feature before completing the full form. Another recommendation is to back up your form to a Word Document before submitting.
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*
Street Address City State / Province / Region ZIP / Postal Code
Additionally Insured-Certificate Holder
Name or Company*
(Should be listed exactly as required within contract)
Address*
Street Address Address Line 2 City State ZIP Code
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*
Drop files here or

Accepted file types: pdf, doc, docx, jpg, gif, png.
Accepted files are .pdf, .doc and .docx. jpg, gif, png 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.
Thank You
Please only click submit ONCE. Attachments may take 30-60 seconds to upload.
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later