Insurance Certificate Request Form
Franchise - Team *
First Name *
Your answer
Last Name *
Your answer
E-mail *
Your answer
Cell Phone / Texting Number *
Your answer
Location Information - To Be Insured
Please make sure that you communicate with your cities, schools, and churches to get the EXACT WORDING AND VERBIAGE or it will be denied. This will delay the process.
Insurance Cert Year
Name of City, School, Church, etc. *
Your answer
Specialty Wording *
It is common for a Municipality or a School District to require specialty wording such as the below example; (“ABC Unified School District, it’s Officers, Employees, Agents and Volunteers”)
Your answer
Physical Address *
Your answer
Physical City/State/Zip *
Your answer
Mailing Address
Optional
Your answer
Mailing City/State/Zip
Your answer
Phone *
Your answer
Fax
Your answer
Delivery Method *
Email
Your answer
Additional Insured Endorsement?
Your answer
Thank You
Looking forward to a successful season
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