Region Leadership Conference Certificate of Liability Insurance Request Form
completed by the region adviser -- submit no later than two weeks before your event
(RLC) Region Leadership Conference Contact Information
(RLC) FBLA Region Adviser's School/Chapter Name
*
(RLC) FBLA Region #
*
(RLC) FBLA Region Adviser Name
*
First Name
Last Name
(RLC) FBLA Region Adviser Email
*
example@example.com
(RLC) FBLA Region Adviser Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Information for Certificate of Liability
Identify the Event for Which You Need a Certificate of Liability Insurance.
Region Leadership Workshop (RLW)
Region Leadership Conference (RLC)
Identify the Date of the Event.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Institution to Which the Certificate Should Be Issued.
How Many Are You Expecting to Attend This Event
Include Both Students and Adults
Name of Contact Person for this Institution
First Name
Last Name
Phone Number of Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of Contact Person
example@example.com
Mailing Address of the Institution Contact Person
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does This Institution Need to Be Listed as an "Additional Insured" on the Certificate of Liability Insurance? (make sure you have a correct answer)
Yes
No
Save
Submit
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