Insurance Request Form

Arizona Regional Service Committee Inc. P.O. Box 1351 Phoenix, Arizona 85001

All group business meetings and activities are covered with the current insurance policy. Meetings held in club houses are the exception. They are not covered by the current policy. Certificates of insurance will be provided upon request. There is no need to request a certificate if that facility does ask you for proof of insurance. Please fill out the request COMPLETELY.

The Request MUST be submitted a minimum of 30 days prior to the event.
Requester E-mail:*
Event name:*
Start and End Date (if only one day make end date same as start)*
Start Time:*
End Time:*
Event Sponsor (group, area or regional subcommitte name)*
Facility name:*
Facility Address:*
Mailing address of facility if different from above
Facility Contact person*
Facility Contact Phone:
Facility Contact E-mail:
Facility Fax Number
Insurance Form