Certificate Of Insurance Request Form printable pdf download

USA Pickleball Association

Certificate of Insurance Request Form

Certificates of Insurance are issued as proof of insurance coverage to a third party or certificate holder, such

as the owner of a tournament venue. If required, the certificate holder may be named as an Additional

Insured on USAPA’s liability policy. Please complete all sections of this form to receive a Certificate of

Insurance and, if needed, proof of Additional Insured status.

Mail this completed form to USAPA, P.O. Box 7354, Surprise, AZ 85374 at least 30 days before the event

starts or scan the signed form and email as an attachment to . If you have any

questions about filing out this form, e-mail .

Name of Pickleball Event____________________________________________________________________

Event Dates: Beginning __________ Ending_________. Probable number of entrants __________________

Location (Venue/Certificate holder) of Event ____________________________________________________

Venue Street Address ______________________________________________________________________

City ____________________________________________State ________Zip code_____________________

Venue Contact Person ____________________________________ Phone ___________________________

E-mail ________________________________________________ Fax ______________________________

Does the Certificate Holder require Additional Insured status? Yes _____

No_____

If yes, please specify “additional insured” wording as it should appear: ________________________________

________________________________________________________________________________________

Other named Additional Insureds: (Provide name as it should appear and address if different than above)

1. ______________________________________________________________________________________

2. ______________________________________________________________________________________

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By submitting this request, the event or tournament director and tournament volunteers agree to comply

with the rules and sanctioning guidelines as set forth by the USA Pickleball Association.

Director’s Name ______________________________________ Phone ______________________________

E-mail_______________________________________________

Fax ______________________________

Address _________________________________________________________________________________

City _____________________________________________State ________Zip code ___________________

Signed ____________________________________

Dated _____________________________

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For internal USAPA use only. To insurer: This event has been sanctioned by the USAPA.

Signed: ________________________________, USAPA Representative. Dated: _________________

Certificate Of Insurance Request Form