Request For Certificate of Insurance

Please fill in ALL Information below
List the "Certificate" Holders information, i.e., Board of Ed, City of, Church, etc. (Who is asking for the insurance- (DO NOT PUT YOUR NAME)

* Name (of organization that is asking for the certificate)

* Phone:

Fax:

* Address

* City, Sate Zipcode:

* Amount of Insurance needed:

600,000

1,000,000

Attn:

* Do they wished to be "ADDITIONALLY INSURED"

Yes

* Date of Event

if for meetings, just indicate annual

* What will you be using?

(fellowship hall, classroom, chapel, etc.)

* Name of Event

(Meeting, Camporee, B/G Banquet

* Where is this located

* Is there a Fee?

Yes

* How Much?

if zero enter 0.00

All Certificates must have a unit member contact. They will receive a copy

* First name

* Address 1:

* Last Name:

* City, State zipcode:

Phone (work):

Fax:

* Phone (Home):

* Email

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