SGR Certificate of Insurance Request

To request a copy of the Certificate of Liability Insurance coverage for your upcoming event, please complete the following information. Please allow 7 – 10 business days for completion.

Contact administrativeassistant@sgrho1922.org and compliancespecialist@sgrho1922.org with questions.

CHAPTER INFORMATION

Region *

Chapter Type *

Chapter Name *

Submitter First Name *

Submitter Last Name *

Submitter Role *

Submitter Email address *

Submitter Phone Number *

Submitter Fax Number

*

I attest that I have secured approval from the chapter basileus to submit this request.

UNDERGRADUATE ADVISOR INFORMATION (Required for undergraduate chapters)

Advisor First Name *

Advisor Last Name *

Advisor Phone Number *

Advisor Email address *

FACILITY & EVENT INFORMATION

Name of Facility or Entity *

Date of Event * +

Type of Event *

Street Address *

Address Line 2

City *

State *

Zip Code *

Facility Contact First Name *

Facility Contact Last Name *

Facility Contact Email Address *

Facility Contact Phone Number *

Facility Contact Fax Number

Reason for Request of Certificate of Liability Insurance *

Description on Certificate/Specific Instructions (e.g., names of parties to be listed on the certificate) *

Please upload the venue specific insurance requirements documentation, if applicable.

Certificate of Insurance Fee *

$25.00