Insurance Certificate Request Form

Is this Event a Fundraising Activity? *

Please attach any pertinent information regarding fundraising activities (brochure, advertisement, specific details)

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Note: If the event involves any of the following, please contact Jina Doyle at jdoyle@amerspec.com or 260-673-1127 immediately, as the policy either specifically
EXCLUDES coverage for these events or requires the U.S. Program to meet certain underwriting requirements. Coverage is not provided for the following activities unless approved in advance by the Insurer.

  • Alcohol
  • Rock Climbing Walls
  • Aircraft (other than a Plane Pull)
  • Animals (other than Equestrian practices /competitions)
  • Firearms
  • Fundraising Events lasting more than 7 consecutive days
  • Over the Edge events
  • Inflatable Devices
  • Mechanical Rides
  • Golf Ball Drops
  • Fireworks
  • Rodeos
  • Fundraising Events with more than 5,000 people (including spectators)
Is the Event Sponsored by a Special Olympics Program? *
Is the Event Conducted by a Special Olympics Program? *
Is Alcohol Being Served at the Event? *
Does the Certificate Holder require Additional Insured status*? *

*ADDITIONAL INSURED STATUS SHOULD BE PROVIDED ONLY IF IT IS A REQUIREMENT OF THE CERTIFICATE HOLDER.

Are you required to enter into an agreement/contract/permit with another party relative to the above-refenced event that contains assumption of liablity, indemnification, or hold harmless language? *
Original Certificate should be sent to *
Any questions about the Insurance Certificate Request form, please contact Katie Dennett at 203-230-1201 ext. 245 or katied@soct.org.