Request For Gswpa Certificate Of Insurance Form

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REQUEST FOR GSWPA CERTIFICATE OF INSURANCE FORM
Purpose: This form is used when an outside organization, such as a school or church, requests a copy of GSWPA’s
certificate of insurance.
Instructions: Complete and submit at least (3) weeks in advance. You can either:
Mail To:
GSWPA
Certificate of Insurance Request
30 Isabella St. Suite 107
Pittsburgh, PA 15212
OR
Email to:
Garret Myers at
After we receive your form, we will send the Certificate of Insurance to the location contact using the
submission method you enter below.
Troop Information
Troop Number: ____________ Service Unit: ____________ Name of Certificate Requestor: _____________________
Requestor’s Phone Number: ___________________ Requestor’s Email: ____________________________________
Type of activity certificate is needed for: ______________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date(s) of activity: ________________________________________________________________________________
Issue Certificate of Insurance To:
Location Name: ____________________________________________________________________________________________
Is location at a school?  Yes  No If Yes: School Name: _______________________ School District: _____________________
Address: __________________________________________________________________________________________________
Street
City
State
ZIP
Location Contact Name: _______________ Location Contact Phone: ____________ Location Contact Email: __________________
Send Certificate to:
 Email: _________________________________________ Attention To: _____________________________________________
 Fax: ___________________________________________ Attention To: _____________________________________________
 Address Listed Above
 Other Address: __________________________________________________________________________________________
Street
City
State
ZIP
Signature
_________________________________________________________________________________________________________
Requestor’s Signature
Date

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