Certificate of Insurance Request Form

This form is for Club Directors/Administrators ONLY. Insurance is only valid for events in which ALL participants are USAV members. Certificate holder is generally an entity, such as a school district, church, facility, etc. Individual schools that are part of a school district do not need to be listed, just the district name and the district office address. Turnaround time on COI requests is 3-5 days. Clubs who do not complete the steps necessary to have their club activated by October 6th with CEVA will have their COIs voided.
Club Name(*)
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Your Name(*)
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Your Email(*)
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Your Phone Number(*)
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Club Address(*)
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Need by Date(*)
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Certificate Holder Name (i.e. school district, facility, etc):(*)
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Certificate Holder Address:(*)
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Certificate Holder email:(*)
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Certificate Holder email 2:
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Limits of Coverage Requested:(*)

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Insurance Coverage Requested For:(*)

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Notes
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Please type the letters you see on the right in the box below.(*)
Please type the letters you see on the right in the box below.
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USAV dualRegionWeb

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Columbia Empire Volleyball Association
4840 SW Western Avenue, Suite 450
Beaverton, OR 97005

503-644-7468

region@cevaregion.org