Certificate of Insurance Request

Personal Information

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Your Name:
Phone/Extension:
Email:
Department Name:

Certificate Holder

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Certificate Holder: (e.g. City of Chicago, Eastbrook School Corp., Marion General Hospital)
Certificate Contact Person:
Email:
Phone Number:
Fax Number:
Address:
City/State/Zip:	/ AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY /

What is the purpose of this certificate? (Check all that apply)

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Proof of insurance

Proof of Professional Insurance (e.g. student nurses, student athletic trainers, etc)

"Additional Insured" Certificate Holder needs to be named as an additional insured (this is usually a requirement in a contract)

Check all that would apply:

General Liability Insurance

Auto Liability

Workers Compensation Liability

Umbrella Policy

Student Professional Liability

Builders Risk

Please Explain the Request and Include any Special Wording, Instructions, or Comments:

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Date Needed by: