Certificate of Insurance Request Form: Swim Alberta Association

This form is only used if a facility requests to be named on the Certificate of Insurance.

PLEASE ALLOW THREE (3) WEEKS PRIOR TO YOUR EVENT FOR PROCESSING TIME.

Thank you.

Club Information:

Club Name

Cluob Contact Name

Club Contact Phone

Club Contact E-mail

Date of Submission:

dd/mm/yyyy

Details of Event (What are you doing? Where are you going? Who's attending?)

Activity Type

Annual Facility CertificateTraining/Competition - In Alberta or Canada but outside your regular facility
Training/Competition - Outside Canada Other

Description of Event

Dates of Activity

Times, if Applicable

Numbers of: Coaches

Swimmers

Chaperones

Please list all chaperones, if applicable

Requesting Facility Information

Please provide accurate and exact information to be listed on the Certificate of Insurance.

Name of Facility &/or requesting municipality

Address

City

Province/State

Country

Postal/Zip Code

Facility Contact Name

Contact Phone

Contact Email

Is a 30 Cancellation required?

YesNo

If the facility requires specific wording, enter it here. Please note that Canadian insurance verbiage is different than in the US.

A signed contract may be requested by the broker or Swim Alberta. If a request is made, the Certificate of Insurance will not be issued until the contract has been received and reviewed.