FORM Request For Certificate Of Insurance

User Manual: FORM-Request-for-Certificate-of-Insurance

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Request for Certificate of Insurance
Please complete and forward to Council office:
Fax: 717.394.7776 or email: leslie.rohrer@scouting.org
Complete Shaded Areas
Certificate Holder (Organization/Business)
Organization/Business:
Contact Name:
Address:
City, State Zip:
Contact Telephone:
Contact Email:
Contact Fax Number:
Amount Needed:
Unit Type and Number:
Start Date:
End Date:
Purpose:

Requestor Information
Name
Telephone
Email

630 Janet Avenue, Suite B-114,
Lancaster, PA 17601
(717) 394-4063 Fax: (717) 394-7776



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