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NCR Certificate of Insurance Request Form
For details about NCR coverage visit our
Insurance page
. Certificates will be issued within 2-3 business days of the request.
Certificates issued by Lockton Companies
1185 Avenue of the Americas, Suite 2010, New York, NY 10036
(646)-572-7300
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* Indicates required question
Email COI request to:
*
Your answer
Date needed by:
*
MM
/
DD
/
YYYY
Club / Venue Information
Required insured information from Club.
Club / Venue name:
*
Your answer
Club's registered Coach:
*
Your answer
Name Insured/Coach Name: (as it should appear on COI)
*
Your answer
Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
ZIP Code:
*
Your answer
Your Name:
*
Your answer
Your email address:
*
Your answer
Your phone number:
*
Your answer
Certificate Holder Information
(ie. City, Field owner, etc.) Who is requesting the certificate.
Certificate holder Name:
*
Your answer
Attention:
Your answer
Address of certificate holder:
*
Your answer
City of certificate holder
*
Your answer
State of certificate holder:
*
Your answer
ZIP of certificate holder:
*
Your answer
Email of COI requester:
*
Your answer
Fax of certificate holder:
Your answer
Additional requests/Description/Reference/Special Instructions:
Your answer
Additional insured/interests: (check all that apply)
Additional Insured
Additional Insured Vendor
Lessor
Other:
Waiver of Subrogation: (check all that apply)
General Liability
Excess
Other:
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