BFL CANADA Risk and Insurance Inc.
2001 McGill College Avenue
Suite 2200
Montreal QC H3A 1G1
Tel.: 514 843-3632
Toll free : 1-800-465-2842
CERTIFICATE OF INSURANCE REQUEST FORM
ONLY FOR NON-PROFIT LOCAL OR CLUB
This request must be sent to your Federation
NOTE : Fields with an asterisk (*) must be filled in at all times
* This is to certify to: (name of the City, Sport Centre, etc.
requesting the certificate – not the club’s name)
* Address :
* Named insured: (name of your Federation ):
and (name of your regional office ) :
Your name:
Phone number (daytime)
Fax number:
Email address:
* Name and details of event:
* Location of the event:
* Date(s) of the event:
Type of insurance
Insurer
Commercial Liability
Insurance for non
profit organizations
AIG Insurance Company of
Canada
Policy n
Policy Period
6645-7871
December 1st, 2015
to
December 1st, 2016
Insurance Limits
(Canadian Funds)
$5 000 000
per loss
______# of days for cancellation notice (if required)
ADDITIONAL INSURED: (Legal name of entity (ies))
IF ADDITIONAL LIST ATTACHED, PLEASE CHECK
1.
3.
2.
4.
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.
FOR FEDERATION USE ONLY:
Certificate request form
approved by:
Person in charge (please print):
Signature
Date:
Phone number:
Email address:
IMPORTANT : You must send this request to your Federation for approval. Please include a copy of the contract between you
and the owner of the facility (ies) you will be using.