Certificate of Insurance Request Form

  • 2001 McGill College Avenue, Suite 2200 Montreal QC H3A 1G1 Tel.: 514 843-3632 Fax: 514 843-3842 Toll Free: 1-866-688-9888

  • (Name of entity requesting proof of insurance)
  • NATIONAL INLINE HOCKEY ASSOCIATION Unit 4, 17 3rd ave N.E., Dauphin MB, R7N0Y5

  • (ie. Roller Hockey practices / games / tournaments)
  • / /
  • / /
  • Name: Address:
  • THE ABOVE ENTITIES WILL BE ADDED TO THE POLICY AS ADDITIONAL INSURED BUT ONLY WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED DESCRIBED ABOVE. THE CERTIFICATE APPLIES TO THE MEMBERS AND AUTHORIZED PERSONNEL OF THE INSURED WHILE OPERATING WITHIN THE SCOPE OF THEIR DUTIES AND APPLIES ONLY TO THE DATES OF THE EVENT AS MENTIONED ABOVE.