Request for Certificate of Liability Insurance

1. Requests are acknowledged only from California Youth Soccer Assn. Inc. affiliated Leagues. 2. A separate form MUST be completed for each Named Certificate of Liability Insurance request. 3. All requests MUST be submitted and signed by your DISTRICT COMMISSIONER before the Cal North State Office will process your request. 4. Appropriate fee(s) MUST accompany all requests that are submitted. (Cash, Check or Visa/MasterCard will be accepted) a. $10.00 per certificate if request are made within six (6) business days. b. $20.00 per certificate if the request is made less than five (5) business days. 5. General Endorsement(s) with the Insurance Certificate MUST include a copy from last year, or attach the special instructions to this request. 6. Certificates will be forwarded to the League address that is provided on this form or you may provide a maximum of 2 email addresses and a pdf copy of the certificate will be emailed. 7. A COPY OF THE CERTIFICATE WILL BE MAILED DIRECTLY TO THE NAMED INSURED ONLY IF YOU HAVE INCLUDED A SELF ADDRESSED AND STAMPED ENVELOPE. 8. Once Cal North receives the approved Insurance Certificate request the process could take up to seven (7) business days.

1. Requests are acknowledged only from California Youth Soccer Assn. Inc. affiliated Leagues. 2. A separate form MUST be completed for each Named Certificate of Liability Insurance request. 3. All requests MUST be submitted and signed by your DISTRICT COMMISSIONER before the Cal North State Office will process your request. 4. Appropriate fee(s) MUST accompany all requests that are submitted. (Cash, Check or Visa/MasterCard will be accepted) a. $10.00 per certificate if request are made within six (6) business days. b. $20.00 per certificate if the request is made less than five (5) business days. 5. General Endorsement(s) with the Insurance Certificate MUST include a copy from last year, or attach the special instructions to this request. 6. Certificates will be forwarded to the League address that is provided on this form or you may provide a maximum of 2 email addresses and a pdf copy of the certificate will be emailed. 7. A COPY OF THE CERTIFICATE WILL BE MAILED DIRECTLY TO THE NAMED INSURED ONLY IF YOU HAVE INCLUDED A SELF ADDRESSED AND STAMPED ENVELOPE. 8. Once Cal North receives the approved Insurance Certificate request the process could take up to seven (7) business days.

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