Insurance Certificate Request Form

Group Insurance Request Form

The Insurance Coordinator is the only point of contact. Do not contact the insurance company. Please send any questions and comments to the Insurance Coordinator by email at Insurance@scws-al-anon.org.

Please submit this form 3 weeks in advance of any deadlines and allow at least 10 business days for a response.

After you click “Submit” this form will go directly to the Insurance Coordinator and be provided to the insurance company. The insurance certificate will be sent to Group Member email address and the facility email address provided.

If required by your facility, use this form to request an Insurance certificate for your Group meetings.

Request Insurance Certificate

Date

Insurance Request Type

New Request
Renewal Request
Update Information

Insurance covered request

Name of Group Member submitting this request

Group Member Phone

Group Member Email

Group WSO ID # (required)

Note: Only SCWS physical groups which are registered, active status, meeting physically and published are eligible for insurance coverage. If you don't know the WSO ID number, click here.

Group Name

Meeting Day and Time

Facility / Location Information

Contact Person for the Physical Location to be covered by insurance.

Email address for the Physical Location to be covered by insurance.

Phone number for the Physical Location to be covered by insurance.

Meeting Place Name

Meeting Location Address

Address Line 1

City

State

Zip Code

Some facilities request that they are listed as Additional Insured on the Insurance Certificate

Don't ask them, but if your meeting location APPROACHES YOU to say that they require additional endorsement information on the certificate, THEN you must provide a signed copy of the lease/rental/use agreement between your meeting and the facility approving use of the meeting room. This must be submitted BEFORE the Insurance Certificate can be provided. A new rental agreement must be resubmitted each time your facility renews the rental agreement.

Your meeting name on the agreement must begin with SCWS, for example,

"SCWS - Saturday Afternoon Literature Study"

This will not affect your meeting name with WSO.

Please attach the agreement below.

Important Notes

Babysitting

If your meeting offers babysitting, please be aware that the insurance coverage supplied by the Area does not cover this.

Contact

For questions email insurance@scws-al-anon.org.

The Insurance Coordinator is the only point of contact. Do not contact the insurance company.

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