Insurance Pro Forma

Name of submitter:	x
Your email address:
Your phone number:
Your Fax number:

The Rotary Club of:
wish to advise that it will be running the following event(s) as part of its activities and requires that this activity be noted and included in the insurance policy of District 9790
Brief description of activity:
Date of activity:
Time of activity (when and for how long):
Location of activity:
Are there third parties involved?:	Yes No
If yes please provide details:

Travel arrangements:
Approx number of community participants:
Have you completed risk management form?	Yes No

Is a certificate of currency required?	Yes No
If yes, provide details of parties to be noted:
Any queries or questions should be addressed with the District Insurance officer in order to obtain prior agreement from the insurer. Don’t assume. Obtain confirmation of cover under Rotary insurance