Oregon Federation of Square and Round Dance Clubs

REQUEST FOR CERTIFICATE OF ADDITIONAL INSURED

This form is to be filed when a Federation club is going to have a dance or dance event at a location other than their normal hall, when the facility requires a certificate, or need to be named as an "Additional Named Insured".

One of the most common mistakes made when filling out this form is the name of the additional insured. PLEASE NOTE that this needs to be the owner, owners, or organization of owners who want their names added to our liability insurance. In many cases, the owner of the facility is not the same as the name of the facility that you are using. An "IOOF Hall" is probably owned by an organization called "IOOF Lodge #23", for example.

The "Facility Name" means the name of the actual location of the event. This must include a complete address: street, city, state, and zip.

When you submit this form, I will generate a PDF file that you can view with the Acrobat Reader. Most people like to look this form over BEFORE it gets submitted to the insurance chairman. The "Preview" button will do that: it shows you a copy of the form, WITHOUT sending it. When you are finally happy with the form, use the "Submit" button instead.

When you click "Submit", a copy will be sent by email to the Federation insurance chairman. If you check the box below, a copy will also be sent to you by email.

ALL INFORMATION MUST BE PROVIDED.

Association: Oregon Federation of Square & Round Dance Clubs
Council:
Information About the Additional Insured
Additional Insured Name:
Street Address:
City:
State:
Zip:
Location of Event(s)
Facility #1 Name:
Street Address:
City:
State:
Zip:
Facility #2 Name:
Street Address:
City:
State:
Zip:
Information about the Function(s)
DateTimeType of Function
Information About the Requesting Club
Name of Club:
Person Making Request:
Address:
City:
State:
Zip:
Phone:
E-mail:
Please e-mail a copy of this form to me.
Additional Comments