REQUEST FOR CERTIFICATE OF INSURANCE
(Please print legibly or type)
PLEASE FILL OUT COMPLETELY
TO: Robert S Hinderliter – Trading Post Manager
Phone: 610-696-2900 x10 Fax: 610-696-3389
Email: Robert.Hinderliter@scouting.org
FROM:
Requestor
PHONE: Ext. Fax #:
EMAIL ADDRESS:
Unit, District or Council Activity?
Which unit or district?
Description of activity/event
Date(s) of activity
Location of actual event & description of facilities used:
** FOR ALL CUB SCOUT DAY CAMPS **
• Attach a copy of lease agreement/contract, specifically the pages that include indemnity language and insurance requirements.
• Scout executive confirmation that the camp program will be conducted in accordance with established standards as set in National Standards for BSA Local
Council Accreditation of Cub Scout/Webelos Scout Day Camps, No. 13-108, and that the day camp director and program director hold current training
certification through the National Camping School.
Scout Executive Initials:
_______________
Limits Requested: $
Certificate holder/Organization Requesting Certificate (Complete name and address):
Has the certificate holder requested to be listed as additional insured? Yes No
Are any fees required for services, use of property, etc? Yes No
If so, Amount being charged?
If certificate is for a unit activity, is the certificate holder the chartered organization for the unit involved? Yes No
Additional comments:
Please allow at least 2 weeks for processing of certificates to avoid delays and the possibility of not
receiving your certificate in time.
THE STANDARD INSURANCE REQUEST MAY TAKE UP TO 5 WORKING DAYS. THE EXTRA
INSURANCE REQUEST (OVER 1M) MAY TAKE UP TO 10 DAYS.
** REQUESTS ARE PROCESSED IN THE ORDER IN WHICH THEY ARE RECEIVED **
*** PLEASE ATTACH A COPY OF ANY AGREEMENT, CONTRACT, PERMIT OR APPLICATION
FROM THE CERTIFICATE HOLDER INDICATING THEIR INSURANCE REQUIREMENTS.
IF THIS IS NOT INCLUDED THE CERTIFICATE CANNOT BE PROCESSED!
