Customer Service

Request Certificate of Insurance

Every once in a while your religious organization or senior community may participate in an event that requires a Certificate of Insurance, which temporarily adds coverage to complement your existing insurance coverage. Examples include a holding a special event at a public park, a field trip to a local lake or swimming pool, or even an RV rental for a road trip.

Organization Name - This is the "proper" name of your organization, as it is shown on your organization's policy or invoice.

Event Information

Please provide the name of the event, describe the activities involved or other sport related or any athletic type of activities sponsored by the organization during the event. (The certificate of insurance will be issued in connection with the activity described.)

One TimePeriodicIf the event is a regularly sponsored event scheduled annually or several times per year an endorsement to your policy may be necessary.
Example: 1/2 equals 1 Adult for every 2 Children
Bounce House/Swimming requires a separate survey.

Certificate Holder

One requesting the certificate (e.g. facility, event sponsor, etc.)

The Certificate Holder is the organization, entity, or individual asking you for evidence of insurance. It is not your organization.

Deliver to Certificate Holder by*

MailFaxEmail

Deliver to Certificate Holder by*

Does the certificate holder require special coverage such as to be named additional insured?*

YesNoAdditional Insured should only be checked if it is a requirement of the Certificate Holder. You should avoid adding another party as an additional insured when possible. We can verify that you have insurance without adding another party as additional insured. Additional Insured is a person other than the named insured who is protected under the terms of the insurance policy and are added by endorsement. Additional insured certificate is usually required by contract and extends your coverage to the additional insured. Usually there is an underlying contract that outlines what additional risk you are assuming.

Has the organization entered into any contract or permit relating to this event?*

YesNoIf you have entered into any written agreement, application, contract, or permit, a copy of the document must be provided. If it is not provided, the certificate could be delayed.

Certificate required by (date)?*

*Please make sure all form fields have been completed before submitting.
DISCLAIMER: Providing a copy of any written agreement, application, contract or permit is for the sole purpose of reviewing the insurance requirements and to determine if your current insurance program placed with our Agency addresses the types and amounts of insurance coverage referenced by the contract. Our Agency is not providing legal advice or a legal opinion concerning any portion of the contract nor is the Agency undertaking to identify all potential liabilities that may arise under the contract.