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 weeks prior to your event for processing time. Thank you.

Club Information:

Club Name

Club Contact Name

Club Contact Phone

Club Contact E-mail

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

Activity Type

Dates, if Applicable

Times, if Applicable

Numbers of: Coaches

Swimmers

Chaperones

Please list all chaperones, if applicable

Requesting Facility Information

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

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.

Please upload a copy or scan of your contract.

A scan of your contract MUST be included with this form.

Date of Submission:

dd/mm/yyyy