Request for Certificate of Insurance

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Provided by Missouri Youth Soccer Association

Email *

Name of Person requesting *

Please select what type of member you are: *

Member Club

Member League

Independent Team

Club / League or member team name *

Name of Facility to be covered in COI *

Full address of Facility to be covered in COI *

Special Instructions:

I understand that COI's do not cover a private residence or property not designed for soccer *

Yes

Required

I understand that this does not provide teams with coverage for indoor leagues with "walls" (i.e. dasher boards as found on indoor soccer fields) unless approved after inspection. *

Yes

Required

I understand that by extending insurance coverage over an indoor space that MYSA does NOT provide coverage or assume any liability for any transmission of COVID-19 or other socially transmitted disease. Every entity that requests coverage must create and implement of mitigation plan that is within the guidance of their local health authorities. *

YES

I affirm that all players participating are registered with Missouri Youth Soccer Association *

Yes

Required

I affirm that I am in possesion of a fully executed USYS Medical Waiver for each participant *

Yes

Required

Your e-mail for Certificate to be sent to: *

Contact Phone Number: *

YYYY

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