COI Request Form

This form is for NA Groups that are asked to provide proof of insurance coverage to the facility they are holding meetings at.

If you are hosting an NA event, you only need to fill out the Event Submission Form. That will add the event to the calendar and will also send the necessary information for a COI for the event.

Certificate of Insurance Request

Company
This field is for validation purposes and should be left unchanged.
Group Name*
Facility Name*
Address*
Street Address Address Line 2 City State ZIP Code
This field is hidden when viewing the form
Facility Email Address (If Available)
Meeting Day(s)*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
This field is hidden when viewing the form
Frequency*
- One Time
- Recurring
Start Time (ex: 07:00)*

: HH

MM

AM/PM
End Time (ex: 08:30)*

: Hours

Minutes

AM/PM
Group Contact 1*
First Last
Phone*
Email*
Group Contact 2
First Last
Phone
Email