MOWW Fm 10c, Request for Insurance for MOWW Event (E-Submission)

This form is used for MOWW to request insurance for your unit's MOWW Event.

Note: For accurate review, please submit requests for Insurance no less than 30 days prior to the event.

Requesting Organization

Requester's Name(Required)

Event Name(Required)

Start Date of Event(Required)

Duration of Event(Required)

Number of Days

Facility/Institution Information

Name of Facility/Instituion(Required)

Facility Point of Contact Full Name(Required)

Facility Point of Contact Title(Required)

Facility Point of Contact Email Address(Required)

Facility Point of Contact Phone(Required)

Mailing Address for Facility Point of Contact(Required)

Street Address Address Line 2 City State ZIP Code

Is there a Second Facility Point of Contact?(Required)

This applies ONLY in special situations.

Facility Point of Contact #2 Full Name(Required)

Facility Point of Contact #2 Title(Required)

Facility Point of Contact #2 Email Address(Required)

Facility Point of Contact #2 Phone(Required)

Mailing Address for Facility Point of Contact #2(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

MOWW coverage includes a Blanket Additional Insured endorsement meaning that parties are added as additional insureds automatically as long as there is a signed written contract or agreement in place requiring that status. However, some facilities/venues require that named additional insured be specified on the certificate of insurance (COI).

If a list is required and not provided, the COI received will be insufficient and you will have to resubmit your request again but with all the information needed, and likely will incur at least a 10-day delay for your facility/venue to receive the COI needed for your event.

Does the contract or agreement with facility/venue require additional insured party to be covered?(Required)

Please list the additional insured parties that must be specified on the certificate

(e.g., guards, board members)

One name per row, please. Use as many rows as necessary by hitting the "+" sign.

MOWW Coordinator Information

MOWW Chapter

MOWW Coordinator's Name(Required)

MOWW Coordinator's Event Title(Required)

MOWW Coordinator's Email(Required)

MOWW Coordinator's Phone(Required)