REQUEST FOR CERTIFICATE OF ADDITIONAL INSURED FOR SPECIAL DANCE
This form is to be used for notification of an event, when a Certificate is required

Please TYPE OR PRINT with ballpoint pen.

LOCATION…means the name of the actual Location of the dance. State complete address: street, city, state and zip code.
NAME OF THE ADDITIONAL INSURED… means the owner or organization of the owners that wants their names added to your liability insurance. Normally this differs from the name of the facility being used or the location of that facility.
DATE (S)…means special dance date. “Example: Every Saturday in 20xx is OK”

LOCATION OF EVENTS _________________________________________________________

STREET ADDRESS_______________________________________________________

CITY________________________________STATE______________ZIP____________

NAME(S) OF ADDITIONAL INSURED_____________________________________________

___________________________________________

STREET ADDRESS_______________________________________________________

CITY_____________________________STATE__________________ZIP___________

LIST ALL BUILDINGS USED_____________________________________________________

DATE(S) AND TIME OF EVENT___________________________________________________

TYPE OF EVENT________________________________________________________________


Requested by (club/ organization name)______________________________________Date____________

Person making request____________________________________________________________________

Phone: _________________________ Street Address___________________________________________

City_________________________________State_________________Zip_________________________



SEND TWO COPIES OF THIS FORM COMPLETED TO:
S C SQUARE AND ROUND DANCE FEDERATION
John and Rosilyn Earley
9422 Plowden Mill Road
Alcolu, S.C. 29001