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Request For Certificate Of Insurance
Request For Certificate Of Insurance
Insured Name
Address
City
State
Zip
Requested by
Position at Church
Email
Phone
Fax
Certificate Holder / Additional Insured
Name
Address
City
State
Zip
Attention
Fax
Certificate Holder To Be Named
Additional Insured
Select One
Yes
No
Loss Payee
Select One
Yes
No
Evidence of
Property Damage
Select One
Yes
No
Landlord
Select One
Yes
No
Mortgagee
Select One
Yes
No
On going?
Select One
Yes
No
Reason for Certificate
(Description of
activity, or
property address)
Dates, Amount of People, Equipment
Special Instructions
Please make sure that all form fields have been completed before submitting.
