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.