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Proof of Insurance Form

Requesting Proof of Liability Insurance
The original certificate will be sent to the organization requesting proof of insurance. A copy of the certificate will be sent to the FCA special events Insurance Department. This completed form must be sent to FCA at least 3 weeks prior to the date of your event. If this is for huddle insurance, please do this immediately at the beginning of your school year.

Name of Event (Huddle):*
Date(s) of Event:*
Approx. # of Participants*
Location of Event:*
Description of Activities*

Organization/School District/Facility Requesting a Certificate of Liability
Name of Organization*
Address of Organization*
City, State, Zip Code*
Attention to:*
Phone*
Fax Number*
Email Address*
Special Instructions
FCA Rep. Responsible for the Event*
Date Submitted*
Signed by:*

FCA Special Events Insurance Dept./8701 Leeds Rd/Kansas City MO 64129/816-892-1132/816-892-2136 (fax)

* indicates a required field

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