LLB Certificate of Insurance Request

Name of your League:*
Certificate Information:
Name of the Organization Requesting the Certificate:*

(The Certificate Holder)
Mailing Address for Certificate Holder:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Event Start Date (DD/MM/YYYY):*
DD slash MM slash YYYY
Event End Date (DD/MM/YYYY):*
DD slash MM slash YYYY
Is the Certificate Holder to be added as an Additional Insured to the Certificate of Insurance?*
- Yes
- No
Event Information:
Name of Event Location:*
Address of Event Location:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please provide details of the activity & event:*
Request made by:
Name*
First Last
Email*
Date (DD/MM/YYYY):*
DD slash MM slash YYYY
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Speak with a broker to learn more about our Little League Baseball Insurance Program.

613-526-1184

Certificate Information: