PLEASE NOTE: Review your contract or check with your facility to see if they require listing as “additional insured.” If so, you must include a copy of the contract with this request. Contracts and supporting documentation should be emailed to insurance@sccqg.org. See insurance instructions for additional information. Certificate amendments will result in an additional fee.

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 T) - select your guild name

Guild (V 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:

| | | | | | |