Request for Certificate of InsuranceDown Load COI request form and email request to: Wendy@insurance.churchORUse the form below. Church/Insured Name: * Requested By: * First Name Last Name Contact Phone * (###) ### #### Email * Date Certificate Insurance Needed By: * MM DD YYYY *Requests May Take Up to 10 Business Days to Process Certificate Holder: * Certificate Holder Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Certificate Holder Contact Person * First Name Last Name Email * Additional Insured: (Chose all that apply) General Liability Automotive Liability Workers Compensation Property Limit Other Other description Additional Interest: Mortgage/Lessor Location Building Loan # Loan Amount Closing Date Additional Interest: Loss Payee - Leased Equipment/Vehicle Make Model Serial/VIN # Agreement # Location Building Event Location/Permit Information: (All inflatables are excluded) Venue Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Event Date/s: Type of Activity: Comment Any additional information you want us to know about you or your organization. Thank you! Our agent will be in contact with you soon!
