Request for Certificate of Insurance for Branch Event

Request for Certificate of Insurance for Branch Event

Please fill in the details of the event for which you would like a Certificate of Insurance issued. This online form will be submitted to Anthony DiFilippo at ESU US National Headquarters. Please direct any questions to him at the contact info below.

Please note that a Certificate will not be issued to a Branch delinquent in submitting to the National Headquarters the annual insurance premium of $250.00.

Address for submitting premium:
National Headquarters
144 East 39th Street, New York, NY 10016
Phone: 212-818-1200 ext. 228
E-mail: adifilippo@esuus.org

Indicates required field (*)

Name of the venue where the event will be held: *
Venue Street Address: *
Venue City: *
Venue State: *
Venue Zip Code: *
Contact Person at Venue: *
Telephone Number for Venue Contact: *
Date of the event: *
Time: *
Branch: *
Branch Officer Making the Request: *
Title/Position: *
Telephone: *
E-mail: *