CERTIFICATE OF INSURANCE REQUEST FORM
Issued by GSWPA
This form is used when a certificate of insurance is requested by an outside organization,
such as a school or a mall.
Instructions: Complete and submit at least three (3) weeks in advance to:
GSWPA, Certificate Request, 30 Isabella Street, Suite 107, Pittsburgh, PA 15212
Troop #
Service Unit
Date(s) of activity
Type of activity certificate is needed for
Name of Volunteer requesting certificate:
Phone-Day
Phone-Evening
Email address
Please issue certificate to:
Location* Name:
Address
Street
City
State
Zip
Attention (Contact name):
Contact Phone
Contact email
*If this for a school location, please indicate school name, district and location:
School Name
Address
School District
Street
City
State
Zip
Send certificate to:
Email
Fax
Above address
Other address
Attn:
Attn:
Street
City
State
Zip
The council copy of the certificate will be sent by first class mail unless an email or fax number is provided above.
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