Certificate of Insurance Request form

Main Contact

You will receive a confirmation by email.

First name *

Last name *

Email *

Mobile

Choose your Dojang/Club *

Choose your Dojang/Club

Insurance Coverage *

$2,000,000 $5,000,000 x Clear

Other

Effective Date and Time - From:

Effective Date and Time - To:

Activities/Description of Operation/Event Details

Location(s) of the Activities

Facility Name *

Address *

City *

Country *

State/Province *

Region *

Zip/Postal code *

Additional Locations

Facility Name *

Address

City

Country

State/Province

Region

Zip/Postal code

Please provide the name of the entity who is requesting the insurance certificate. For example if you are renting a community centre in Winnipeg, the City of Winnipeg requires the insurance certificate so please list them as the additional insured.

Additional Insured #1

Additional Insured *

Address

City

Country

State/Province

Region

Zip/Postal code

Additional Insured #2

Additional Insured *

Address

City

Country

State/Province

Region

Zip/Postal code

Electronic signature

Please sign your name inside the box

Type your name

Signature style

Electronic signature Signature pad

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Please accept all conditions.

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Email or mobile

Connection code

Waitlist

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