CSRDS Named Insured Certificate from AON
Request Form
Where indicated please enter the statement that is shown bold within quotes ("...")
Enter "
A Named Insurance Certificate is required for
"
O
rganization :
Tom Brown School Board (Example only replace with your info)
Address :
11 Main St. Anytown, NL (Example only replace with your info)
E-mail or Fax # :
Where certificate is to be sent
Type of event :
Type of event certificate is required for :
Enter "
Additional Insured's required
"
Full name :
Address :
CSRDS Member requesting
:
Federation/ Association/Club
Enter "
Current CSRDS Membership #
"
CSRDS membership #
Mandatory
:
2009/= 123456
(Example only replace with your info)
Enter "
Requestors Name & Position
"
Requestor's name :
James Jones (Example only replace with your info)
Address :
11 Main St. Anytown, NL (Example only replace with your info)
Telephone # :
include area code 123-456-7890 (Example only replace with your info)
E-mail :
JamesJones@wherever.ca (Example only replace with your info)
Requestor's position :
Select...
President
Secretary
Treasurer
Other Officer
Please select one : President, Secretary, other officer
more info if needed :
write any other information if required
send via email
Revised 06 Feb 2009