REQUEST FOR CERTIFICATE OF INSURANCE Church Name: Address: City: State:      Zip: Requested By: Email Address: Phone Number: Fax Number: CERTIFICATE HOLDER: Name: Address: City: State:      Zip: Attn: Fax: CERTIFICATE HOLDER TO BE NAMED: Additional Insured  YES      NO Loss Payee  YES      NO Evidence of Property Insurance  YES      NO Landlord  YES      NO Mortgagee  YES      NO Reason for Certificate: (description of activity, or property address): Dates, Amount of People, Equipment: Special instructions: Please make sure all form fields have been completed before submitting.

201 Cajon St. Redlands, CA 92373 Phone: 909-307-8500 Fax: 909-307-1245 info@cutlerinsurance.com Lic.#0333750

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