Certificate of Insurance (COI) Request
This form must be completed by state or district associations requesting a Certificate of Insurance (COI) from National FBLA for venues, conferences, or events. Please allow at least 10 business days for processing.
Chapter Information
The chapter information is typically a state or district association name.
State
*
Please Select
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
DODDS
DODEA
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Division
*
Please Select
DIV0 All/Administration
DIV1 FBLA
DIV2 Middle School
DIV3 Collegiate
DIV4 Middle School/High School
Chapter Legal Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State Leader Name
*
First Name
Last Name
State Leader Title
*
State Leader Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State Leader Email
*
example@example.com
Requestor Information
Individual completing form request
Name
*
First Name
Last Name
Email
*
example@example.com
Event Details
Event Type
*
Please Select
Conference
Meeting
Other
Event Name
*
Expected Attendance
*
Start Date of Event
*
-
Month
-
Day
Year
Date
End Date of Event
*
-
Month
-
Day
Year
Date
Location/Description of Event
*
Certificate Holder Details
This information is typically requested by a venue or entity with specific guidelines.
Certificate Holder
*
Certificate Holder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Certificate Holder Contact
First Name
Last Name
Certificate Holder Email
example@example.com
Amount Required
*
Is the organization requesting the certificate to be named as additional insured?
*
Yes
No
Is this certificate of insurance request required based on a contract?
*
Yes
No
Contract/Agreement File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: