Request Certificate of Insurance

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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 Move United 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 Move United Insurance Program will cover the requirements, please contact Ryan Semke (rsemke@moveunitedsport.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. Move United 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.

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View a Sample Certificate of Insurance Form

Request Certificate of Insurance 2024

Date Certificate is Needed By?*
MM slash DD slash YYYY
Chapter Contact Information
Chapter Name*
Chapter Contact*
Chapter Contact Email*
Chapter Contact Phone*
Chapter Contact Alternate Email
Program/Event Information
Program Start Date*
MM slash DD slash YYYY

Cannot Precede Today's Date
Program End Date*
MM slash DD slash YYYY

Date cannot be later than 11/30/2024
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 of Company*

(Should be listed exactly as required within contract)
Address*
Street Address City State / Province / Region ZIP / Postal 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, Max. file size: 64 MB.
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
Email
This field is for validation purposes and should be left unchanged.

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Request Certificate of Insurance

PLEASE SCROLL DOWN TO COMPLETE CERTIFICATE OF INSURANCE FORM

Request Certificate of Insurance 2024

Chapter Contact Information

Program/Event Information

Additionally Insured-Certificate Holder