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Certificate of Insurance Request


When organizations rent fields or facilities, the owner often asks for proof of insurance.  This form is used to request a Certificate of Insurance.  The second line asks for the name of the additional insured -- that is where you enter the name of the facility/field as well as how they would like it listed, e.g., "Town of Andover Parks & Rec."  Please provide a fax number if you need the certificate soon; we cannot email a certificate.  If no fax number is provided it will be mailed to the Requestor.

If you would like a General Certificate of Insurance that shows your organization is insured, please write "general" in the "Additional Insured to be Shown on Certificate" field and we can forward a Certificate without an additional insured.

The Certificate of Insurance will take 24-48 hours to process, so please plan ahead!  The certificate CANNOT BE ISSUED if your team or club is not registered with Mass Youth Soccer for the current season.  If you are unsure whether your team or club is registered, please contact Mass Youth Soccer!

If you need more than one certificate, please DO NOT use your "back" button to return to the form.  Please return to the form through the "Resources" menu and be sure to refresh your browser when you open the form.  If you use your "back" button and do not refresh the form, your subsequent requests will not be submitted.

Please note:  This certificate is for games and practices involving the affiliated organization ONLY.  Mass Youth Soccer's insurance coverage does NOT extend to any events run by for-profit organizations.  We will not provide this certificate unless your organization is affiliated with Mass Youth Soccer.  If you have any questions you can reach Kate Murphy at kmurphy@mayouthsoccer.org or by phone at 978/466-8812 x221.


Affiliated Organization: required
The Affiliated Organization is the soccer club or team which is affiliated with Mass Youth Soccer (e.g. Adams Youth Soccer).
Additional Insured: required
The Additional Insured to be shown on the certificate, that is, the name of the facility requesting the certificate. Please be sure to include the complete mailing address of the facility.
Street Address of Additional Insured:
We cannot process a Certificate for an Additional Insured without a mailing/street address!
City:
State:
ZIP Code:
Name of Individual Requesting Certificate (That's You!): required
Your Title: required
Your Mailing Address: required
Your City, State, Zip: required
Your Phone Number: required ( ) -
Your Fax Number: ( ) -
Your Email Address: required
To whose attention shall we fax the Certificate?: required
Their Fax Number: ( ) -
Reason for Certificate Request (practice, tryouts etc.): required
Any Special Instructions?: