BC Region Group/Event Insurance Form

If your group of event requires insurance.

Phone Phone - ### - ### ####
Certificate Holders Information

Please fill out your information in this section for your event/group.
Name Name First Last
Email

Confirm Email Address
Service Position
Area Name
Group/Event Name
Is this a Reoccurring Event?

Is this a Reoccurring Event? Yes No
Is this a Weekly, Monthly or One Time Event?

Is this a Weekly, Monthly or One Time Event? Weekly Monthly One Time Event
Estimated number of attendees
Start Time of Meeting/Event Start Time of Meeting/Event : HH MM AM/PM
End Time of Meeting/Event End Time of Meeting/Event : HH MM AM/PM
Start Date of Event Start Date of Event / MM / DD YYYY
Day/s of the Week

Day/s of the Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Full Address of Meeting/Event Full Address of Meeting/Event
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Venue Requestor Information

This is the company/organization requiring NA to have insurance
Full Business Name of Company/Organization
Full Address of Company/Organization Full Address of Company/Organization
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Organization Office Contact Name Organization Office Contact Name First Last
Organization Phone Number Organization Phone Number - ### - ### ####
Organization Email
Amount of Insurance Required

Amount of Insurance Required $1,000,000 $2,000,000 $3,000,000 $5,000.000
Does the venue/the requestor of insurance require any additional items? i.e. waiver of subrogation, Cross Liability/ Separation of Insured's etc?

Does the venue/the requestor of insurance require any additional items? i.e. waiver of subrogation, Cross Liability/ Separation of Insured's etc? Yes No
Does the venue/the requestor require an additional insured to be named?

Does the venue/the requestor require an additional insured to be named? Yes No
Name of Additional Insured Person/Organization Name of Additional Insured Person/Organization First Last
Address of Additional Insured Person/Organization Address of Additional Insured Person/Organization
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number of Additional Insured Person/Organization Phone Number of Additional Insured Person/Organization - ### - ### ####
Email of Additional Insured Person/Organization
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BC Region Group/Event Insurance Form

BC Region Group/Event Insurance Form

Certificate Holders Information

Venue Requestor Information