Certificate of Insurance Request
Please complete this form for EACH COI requested. Please be complete with your information. All COI's will be processed with information on this request only.
Requestor Email Address
Your answer
Requestor Name
Your answer
Requestor Contact Phone Number
Your answer
Date Needed COI by:
MM
/
DD
/
YYYY
Unit Type and Number
Your answer
Date(s) and Time(s) of Event. If not date specific, please notate.
Your answer
Location Name of Event
Your answer
If applicable: Inside or Outside of a Retail Location
Your answer
Location Address
Your answer
Reason for Event (Fundraising, Camp, etc)
Your answer
Unit Contact Person/Phone Number (on day of event)
Your answer
Certificate of Insurance Holder Listing. Please include ALL requested Certificate holders AND address(es). (Address could be different than location address).
Your answer
Any Additional Insureds (if applicable)
Your answer
Unit District
Required
Notes or Special Requests
Your answer
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