Certificate of Insurance Form

Insurance Certificates for Member teams, Leagues & Events
Certificates of insurance can only be issued to “member teams or leagues” of USA Lacrosse. A member team or league is defined as one that mandates 100% membership in USA Lacrosse for all of its participants. In order for the liability insurance to cover the team or league as an entity, all participants must be members of USA Lacrosse. You can verify the membership and status of coaches and players by going to the secure webpage. If a field owner or facility requires that you provide them with a certificate of insurance, “member teams or leagues” are eligible to do so and may request certificates on behalf of their organization.

NOTE: Coverage applies only to individual USA Lacrosse Member Players, Coaches, Officials and Assigners; and Teams, Leagues and Associations who follow the 100% membership guidelines and are eligible for coverage under this policy. There is NO COVERAGE for lacrosse activities unless those activities are played under USA Lacrosse’s stated definition of allowable rules and guidelines.

Please ensure that the information provided below is correct, especially e-mail addresses, to ensure most efficient processing. Requests will be processed within 24 hours and the certificate will be e-mailed from the Willis Towers Watson (WTW) Certificate Center to the email address provided.

Your Information

Your First Name

Your Last Name

Name of Team/League (if applicable)

Your USA Lacrosse Membership # (if available)

Email Address for Certificate Distribution

Please re-enter Email Address for Certificate Distribution

Certificate is for (select one)

Certificate Holder Information

Certificate type (select one)

* An additional insured certificate names the certificate holder (usually a field owner or facility) as an "additional insured" under the USA Lacrosse policy. This means that the USA Lacrosse liability insurance will be extended to cover the certificate holder in the event a claim arises from the team / league’s negligence during one of your activities. If the field owner or facility is sued as a result of that claim, they would be covered by the USA Lacrosse liability policy for actions arising from the team / league’s negligence, per the terms and conditions of the insurance policy. It is important, therefore, to only issue Additional Insured Certificates to those entities who require per written agreement that you cover them under the USA Lacrosse Insurance program in order to use their facilities. This requirement is typically made in writing or is part of the contract that you may sign in order to use the facility.

*Only field owners or facility owners, whether private, municipal/city or school fields or facilities, can be named as additional insured. Another lacrosse or other sports organization, individual or a golf cart company cannot be named as an additional insured.

* A Proof of Insurance Certificate outlines the insurance coverages in place for your team/league. The proof of insurance certificate names your team or league as the Certificate holder.

Enter the certificate holder information below:

Name of certificate holder

Address

City

State

Zip Code

Additional requirement requests (select which apply)

Additional Insured

Waiver of subrogation

Coverage on a ‘primary/non-contributory’ basis

Are there any special instructions requested by the host site administrator for this certificate (for example, request for specific policy endorsements or required verbiage)?*

Yes

Special Instructions

NOTE: Requests for specific policy endorsements require issuance from the insurance company, and therfore distribution may be slightly delayed. Please allow for adequate time for issuance.

Certification
Please certify your information below.

Member teams, Leagues, and Events: I certify that the team, league, or event on whose behalf I am requesting this certificate mandates 100% membership in USA Lacrosse for all players and coaches. In addition, I have verified our team's or league's events roster and all players and coaches are currently registered members of USA Lacrosse.

I certify that this is true, and I understand that liability coverage is only extended to our team, league, or event if all players and coaches are current members of USA Lacrosse. Further, I acknowledge by clicking on this box that liability claims may be denied for coverage if our team, league, or event does not have 100% registered players and coaches with USA Lacrosse.

Questions about the COI process - please contact Kendall Hyman, WTW Client Manager at Kendall.Hyman@wtwco.com.

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