Liability Insurance Request Form

Please complete and submit the form below to obtain a Certificate of Liability Insurance (COI)

Fédération des sociétés de minéralogie du centre du Canada

Corporate address - CCFMS c/o Natural History, Mineralogy, 100 Queens Park, Toronto, ON M5S 2C6

Mailing address - CCFMS c/o Treasurer, 629 Ester Street, Sudbury, ON P3E 5C6

http://www.ccfms.ca/ CCFMSinsurance@gmail.com

Liability Insurance Request Form (English version)

Co-Operators Policy #1076411149 – March 31, 2025 to March 30, 2026

Co-Operators

#200-797 Milner Ave

Toronto, ON M1B 3C3

Please issue a Certificate of Liability Insurance (COI) according to the following information:

Name (property/site owner name and/or company) & street/mailing address + postal codeWill see this at the top of the COI (certificate of insurance). Please note: that this will never be the club name – it will be the property/site owner’s name & address.0 / 180

Policy InformationThis is the CCFMS mailing address. Please do not change.

Location 2 InformationThis is the CCFMS corporate address. Please do not change.

Notes section on the COI – This is where all additional information is listed. Important that this is filled in completely as possible. We have requested that Co-operators also ensures that this information is included on the COIs.

Form Section

Name of property to be occupied / Collecting site Location and street address of club event.Location and street address of club event. Street addresses for remote locations can usually be found via Google Maps. Can include GPS co-ordinates.

Date(s) of occupancyCo-operators liability insurance covers 24 hours; hence, times of occupancy are not specifically needed.

Type of eventSuch as, monthly meeting, workshop, club show, field trip, picnic, other events, etc.

Any other additional information you would like to be included in the notes.This may include property/site owner requests for additional information.

Name of CCFMS affiliated Club

Club representative can be the President or club member in charge of an event such as, Show Chair, Field Trip Director/Co-ordinator/Leader, Lapidary Workshop Leader, etc. Signatures indicate that any event is club sanctioned / approved.

Name & position of club representative

Please return completed Liability Insurance Request Form, as a Word document per request by Co-operators, to CCFMSinsurance@gmail.com.
Adding a signature:
sign a blank piece of paper in black or dark blue ink – and take a picture;
drag the picture into this document – position it at the blank signature line – and then resize, re-wrap, set transparent background, etc via "picture format".
You should receive your COI within 2 weeks.

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