Request for Certificate of Insurance

Name Insured (Who is the Insurance For?)
Requester*
First Last
Title of Requester*
Requester Email*
Date of Request*
Date Format: MM slash DD slash YYYY
Start Date of Coverage*
Date Format: MM slash DD slash YYYY
End Date of Coverage*
Date Format: MM slash DD slash YYYY
Event*
Location/Venue*
Name of Contact at Location/Venue
Itemized Description of Equipment Being Rented (if any)
Replacement Value of Equipment
Coverage Required*
- General Liability
- Auto Liability
- Excess Liability
- Property Insurance
- Workers Compensation
Additional Insured Required (General Liability)
- Yes
- No
Full Name (exactly as to appear on certificate of insurance)*
Mailing Address (as to appear on certificate of insurance)*
Street Address Address Line 2 City State ZIP Code
Notes/Comments/Special Conditions
If venue has provided their insurance requirements, please upload here.

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