Certificate of Insurance Information Form

Name: Certificate of Insurance Information Form
Start: 2020-10-12T08:00:00-04:00
End: 2025-06-30T17:00:00-04:00

October 12, 2020 @ 8:00 am - June 30, 2025 @ 5:00 pm

Please provide the information necessary to complete a Certificate of Insurance for your Event.

Contact Information
Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Certificate Information
Name of ROTARY CLUB*
Name of Certificate Holder*
The name of the ORGANIZATION who is requesting the Certificate of Insurance from you.
Certificate Holder Address*
Complete the address of the ORGANIZATION who is requesting the Certificate of Insurance from you. A PO Box is not acceptable.

Street Address Address Line 2 City State ZIP Code
Title of Event*
Please provide the name of your event.
Location of the Event*
Identify the name/location of where the event is being held. It may not be the same address of the ORGANIZATION requesting the Certificate of Insurance.
Provide address if different from the Certificate Holder
Street Address Address Line 2 City State ZIP Code
Start Date*
Start and End date may be the same, but both Start and End Date must be completed.
MM slash DD slash YYYY
End Date*
Start and End date may be the same, but both Start and End Date must be completed.
MM slash DD slash YYYY
Start Time*

: Hours

Minutes

AM/PM
End Time*

: Hours

Minutes

AM/PM
Brief Description*
Provide a VERY BRIEF description of your event.
File Upload
If your Certificate Holder has additional information that they want included in your Certificate of Insurance, please upload here! Maximum File Size is 32MB.
Drop files here or

Max. file size: 32 MB, Max. files: 3.

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