Certificate Of Insurance Request Form

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USA Pickleball Association
Certificate of Insurance Request Form
Certificates of Insurance are issued as proof of insurance coverage to a third party or certificate holder, such
as the owner of a tournament venue. If required, the certificate holder may be named as an Additional
Insured on USAPA’s liability policy. Please complete all sections of this form to receive a Certificate of
Insurance and, if needed, proof of Additional Insured status.
Mail this completed form to USAPA, P.O. Box 7354, Surprise, AZ 85374 at least 30 days before the event
starts or scan the signed form and email as an attachment to . If you have any
questions about filing out this form, e-mail .
Name of Pickleball Event____________________________________________________________________
Event Dates: Beginning __________ Ending_________. Probable number of entrants __________________
Location (Venue/Certificate holder) of Event ____________________________________________________
Venue Street Address ______________________________________________________________________
City ____________________________________________State ________Zip code_____________________
Venue Contact Person ____________________________________ Phone ___________________________
E-mail ________________________________________________ Fax ______________________________
Does the Certificate Holder require Additional Insured status? Yes _____
No_____
If yes, please specify “additional insured” wording as it should appear: ________________________________
________________________________________________________________________________________
Other named Additional Insureds: (Provide name as it should appear and address if different than above)
1. ______________________________________________________________________________________
2. ______________________________________________________________________________________
******************************************************************************************************************************
By submitting this request, the event or tournament director and tournament volunteers agree to comply
with the rules and sanctioning guidelines as set forth by the USA Pickleball Association.
Director’s Name ______________________________________ Phone ______________________________
E-mail_______________________________________________
Fax ______________________________
Address _________________________________________________________________________________
City _____________________________________________State ________Zip code ___________________
Signed ____________________________________
Dated _____________________________
########################################################################################
For internal USAPA use only. To insurer: This event has been sanctioned by the USAPA.
Signed: ________________________________, USAPA Representative. Dated: _________________

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