WOGA - Certificate of Insurance

Fill out one copy of this form for each entity to be considered as a Certificate Holder or an Additional Insured. Certificates of insurance listing an entity as a certificate holder can be printed at no charge and are usually sent immediately. If the entity needs to be listed as an additional insured, a charge could apply and the certificate may take 24 hours to process.

Fax:
Email Address:	*
** As it appears on your Participating Member Declaration Certificate
Requested Information
Name of Person Making Request:	*
Proposed effective date:	*
Please select if this is for an Additional Insuredor a Loss Payee.	*

Please specify the nature of the Certificate Holder or Additional Insured entity:	* *
ADDITIONAL INSURED/CERTIFICATE HOLDER/LOSS PAYEE INFORMATION
Give exact name and address of Additional Insured, Certificate Holder, or Loss Payee, as it should appear on the certificate. We must have a complete mailing address or the certificate request will be denied.
Entity Name:	*
Contact Name:
Mailing Address:	*
City:	*
State:	*
Zip:	*
Phone Number:
Would you like the certificate faxed, mailed, or emailed?	*
Email Address:
Email Address Confirmation:
Fax:	*
Information needed to be on the certificate, if for a specific event:
Date of Event:
Location of Event:
Limits
Do you need to increase your limits for this additional insured and event?	*
Per Person:	*
Per Accident limit:	*
Policy Aggregate limit:	*
(Please note that there will be an additional charge for all increased limits and that the aggregate limit can only be increased for the entire policy period.)

REPRESENTATIONS AND WARRANTIES By signing this request form, the Participating Member or Applicant for insurance hereby represents and warrants that the information provided herein and herewith, is true, correct, inclusive of all relevant and material information necessary for the Association to accurately and completely assess the request, and subject to the same representations and warranties made in conjunction with obtaining the Coverage Contract to which the Additional Insured is being requested to be added. IMPORTANT: Insurance is provided to participating members under a Master Group Policy of Insurance issued on behalf of the International Special Events and Recreation Association, a qualified "Purchasing Group" under the Liability Risk Retention Act of 1986-Public Law 97-45. Master Group Policies have been issued to the Association, formed and governed by the laws, rules, and regulations of the State of Utah, to which members will be added as "Participating Members." The Association's program of insurance is a fully insured plan with an insurer permitted to provide insurance in each Association member's state of residence.