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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.