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CERTIFICATE REQUEST FORM

PLEASE READ BEFORE CONTINUING:
Your certificate will be issued to you within two business days of receipt. If your requests requires roster verification or if you need special wording, please allow 5 business days turnaround time from the date all information is received by Bollinger. Please note that we cannot guarantee rush requests.  Thank you.
   
Your Name:
Your League or Chapter Name:
  [use the name shown on your membership registration]
Your Team Name (if applicable):
Mailing Address:
City/State/Zip:
Your Phone Number:
Your Email Address:
Your Fax Number:
Are all members of your Team, League or Event currently members of US Lacrosse? Yes     No

If this is your first certificate request of the new policy term, you will need to forward a roster of all participants to Bollinger for membership verification.
This certificate should be issued on behalf of (please indicate team, league and/or Chapter name here):
Date(s) of event(s) if applicable
Does the Certificate Holder (Field or Facility Owner) need to be named as an Additional Insured? Yes     No
Has your team/ league provided a roster to US Lacrosse or Bollinger for the year in which you are requesting a Certificate? Yes     No

If you need Proof of Insurance, request a certificate naming your team or league as the certificate holder. When the location, i.e., field owner, requests to be named as an Additional Insured, request a certificate naming the location as the certificate holder.
Certificate Holder Name:
Contact Name:
Certificate Holder Address:
City/State/Zip:
Certificate Holder Contact's Phone:

Certificates will be delivered to you. Your organization is responsible for distributing the certificate(s) to the certificate holder(s).
Please indicate preferred method of delivery.  

This document requires Adobe Acrobat Reader. In order to download the Forms above, you must have Adobe Acrobat Reader installed on your computer.  Please click here to download this FREE software.

If you prefer, you can download the request form and fax it to us at: (973) 921-2876 or email it to Lacrosse
Certificate of Insurance Request Form This document requires Adobe Acrobat Reader.
If you have any problems, please call us at (800) 350-8005 press "5" or send an email to Lacrosse@BollingerInsurance.com .