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Please select today's date
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Name
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Street Address, City, State, Zip Code
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E-mail Address
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Phone Number
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Unit Type
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Other
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Unit Number
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District
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Which District do you belong to?
Other
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Unit, District, or Council Activity?
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Brief Description of Activity
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Date(s) of Activity?
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Example: MM/DD/YY-MM/DD/YY
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If certificate is for use of facilities, describe
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Amount needed for certificate of insurance
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If over $1 million please e-mail a copy of the written requirements from the certificate holder.
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Certificate Holder
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complete name and address of place requesting insurance
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Address
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City
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State
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Zip Code
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Has the certificate holder requested to be listed as additional insured?
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Are any fees requied for services, use of property etc.?
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If YES, please answer the next question.
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If so, amount being charged?
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If certificate is for a unit activity, is the certificate holder the chartered organization for the unit involved?
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Additional Comments
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**PLEASE ALLOW AT LEAST TWO WEEKS FOR PROCESSING OF CERTIFICATE REQUESTS. REQUESTS ARE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED.**
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