CERTIFICATE OF INSURANCE REQUEST FORM

Important Instructions - PLEASE READ!

Below is the online version of the Florida Region USAV Certificate of Insurance Request Form. This form can be used to request insurance certificates for up to four facilities at a time that you plan to use during the season. If you need more than four certificates, please complete this form as many times as necessary to fulfill the requirements of your facilities.

Please note that USAV insurance certificates are valid from Sep 1st to Aug 31st of the respective year. Insurance certificates for the new season will be issued after the club has completed renewal for the current season. Clubs may renew their club each year beginning August 1st. Note: The language on the insurance certificate cannot be modified regarding the "Additionally Insured" clause and we cannot provide a copy of the insurance policy, only the Certificate of Insurance with the summary of coverages.

All certificates will be e-mailed to the respective club. Please allow 5-7 days for the certificates to be prepared and e-mailed to your club.

Please contact the Region Office at (352) 742-0080 if you have any questions on this form.

* Indicates required field

Club/ Affiliate Name *

Contact Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Contact Role *

Phone Number *

Email *

Date certificate needed *

Facility #1 information (required)

Facility 1 Name *

Facility 1 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 1 Phone Number *

Facility 1 Email *

Facility 1 Certificate Needed for: *

Event Name (if applicable) *

Facility 1 Certificate Type *

Facility 1 Certificate Requested By: *

Facility #2 information (optional)

Facility 2 Name *

Facility 2 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 2 Phone Number *

Facliity 2 Email *

Facility 2 Certificate Needed for: *

Event Name (If Applicable) *

Facility 2 Certificate Type *

Facility 2 Certificate Requested By: *

Facility #3 information (optional)

Facility 3 Name *

Facility 3 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 3 Phone Number *

Facility 3 Email *

Facility 3 Certificate Needed For: *

Event Name (if Applicable) *

Facility 3 Certificate Type *

Facility 3 Certificate Requested By: *

Facility #4 information (optional)

Facility 4 Name *

Facility 4 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 4 Phone Number *

Facility 4 Email *

Facility 4 Certificate Needed For: *

Event Name (if Applicable) *

Facility 4 Certificate Type *

Facility 4 Certificate Requested By: *

Submit

* Indicates required field

Club/Affiliate Name *

Contact Name *

First

Last

Contact Role *

Phone Number *

Email *

Date Certificate Needed *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility #1 Information (Required)

Facility 1 Name *

Facility 1 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 1 Phone *

Facility 1 Email *

Facility 1 Certificate Type *

Facility 1 Certificate Needed For: *

Facility 1 Certificate Requested By: *

Facility #2 Information (Optional)

Facility 2 Name *

Facility 2 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 2 Phone *

Facility 2 Certificate Type *

Facility 2 Certificate Requested By: *

Event Name (If Applicable) *

Facility 2 Certificate Needed For: *

Facility 3 Name *

Facility 3 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 3 Phone *

Facility 3 Email *

Facility 3 Certificate Type *

Facility 3 Certificate Needed For: *

Facility 3 Certificate Requested By: *

Facility #4 Information (Optional)

Facility 4 Address *

Line 1

Line 2

City

State

Zip Code

Country

Facility 4 Phone *

Facility 4 Email *

Facility 4 Certificate Needed For: *

Facility 4 Name *

Event Name (If Applicable) *

Facility #3 Information (Optional)

Facility 2 Email *

Event Name (If Applicable) *

Facility 4 Certificate Type *

Facility 4 Certificate Requested By: *

Submit

Person requesting acknowledges that insurance coverage is not valid for activities where multiple sanctioning organizations are present.

Please call the Florida Region office at (352) 742-0080 if you have any questions on this form. Mon-Fri, 9a-5p.