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Lions Clubs/District-Certificates of Insurance

In order to expedite the certificate issuance process, you now have the ability to create certificates of insurance on your own. Lions Club members can fill out and print one of these certificates using the form below.

If you need help or have questions on certificates of insurance, please contact our insurance provider by calling either Jeannene Miller at (847) 517-3460 or John Kalush at (312) 288-7397.

Type of Certificate:
Option 1:	This form is used to show proof of insurance. No additional insured is needed.
Option 2:	This form is used to show proof of insurance and to add additional insured's for use of their premises.
Option 3:	This form is used to show proof of insurance and to add additional insured's - State or Political Subdivision - for issuance of permits.

Event Name & Date(s):

Requester Phone Number:
NOTE: Your phone number will NOT appear on the certificate.

Your Club/District:
Name:
City, Territory and Country:

Certificate Holder: This is the individual/entity to whom you are providing the certificate.
Name:
Address:
City, Territory and Country:
Zipcode:

Additional Insured(s):

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