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Your Contact Information
Name
*
Chapter
*
Email
*
Phone
*
Event Detail
Name of Event
*
Description of Event
*
Requesting Party
University
IFC
3rd Party Vendor
Other
*
If other, please describe:
Representative of Requesting Party
*
Email of Representing Party
*
Phone Number of Requestion Party
*
None
Additional Insured (Chapter acknowledges $250 from insurance)
Primary Coverage ($500 additional charge to chapter by underwriters)
Other
*
If other, please describe:
Additional Requirements
Please attach any and all formal document(s) which detail the insurance coverage requirements Examples: recognition statement, student organizational guidelines, event requirements, event contract/agreements, etc. Note: The complete document should be attached.
*
Yes
No (The balance must be paid before a COI can be issued)
I am not sure
*
For more information contact the Pi Kappa Alpha Foundation at (901) 748-1948 or pikeinfo@pikes.org