SCCQG Insurance Certificate Request

Form used to request proof of insurance or proof of insurance with additional insured certificates.

Guild (A thru E) - select your guild name

Guild (F thru O) - select your guild name

Guilds P thru Q - select your guild name

Guild (R thru V) - select your guild name

Guild (W thru Y) - select your guild name

Date(s) of Event*

Type of Function (Select one. Describe in Notes as needed.)*

Legal Name/Owner of Facility to be used:*

Facility Contact Name:*

Address of Facility Contact:*

Facility Contact E-mail:*

Facility Contact FAX (RUSH only):

Address of Facility to be used, if different from above:

Type of Certificate Needed (Select one from the pulldowns)*

Certificate Fee (Select one from the pulldowns)*

Notes (questions/comments - please add here)

Guild Contact Name*

Guild Contact E-mail*

Guild Contact Telephone*

Check No.:

Check Amount:

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