Certificate Holder Name *

Certificate Holder - Street Name *

Certificate Holder - City *

Certificate Holder - State *

Certificate Holder - Zip Code *

Certificate Holder - Email *

AYSO Region, Area, or Section # *

AYSO Region, Area, or Section - Contact Name *

AYSO Region, Area, or Section - Contact Email *

Additional Information or Special Verbiage Requested on Certificate (Note: Items entered here MAY increase the processing time.)

SUBMIT YOUR INFORMATION TO REQUEST A CERTIFICATE OF INSURANCE:

WANT TO LEARN MORE ABOUT PLAYERS HEALTH?

The following endorsements are available below:

- Additional Insured Endorsement (blanket)

- Waiver of Subrogation (blanket)

- Primary & Non-Contributory (blanket)

For questions regarding certificates of insurance or specific endorsement requests, please contact Players Health at ([email protected]).