Certificate of Insurance Request 2017-06-16.xls
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ABCDEFGHIJKLMNOPQRSTUVWXYZ
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REQUEST FOR
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CERTIFICATE OF INSURANCE
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Certificate Holder: Baptist General Convention of Texas
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Name of Div/Area Requesting:
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Name Of Your Event:
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Dates Of The Event:
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Where Event Will Be Held:
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(Must have complete address)
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Physical Address:
(Name)
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(Address 1)
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(Address 2)
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ZIP
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Phone Number:
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Email:
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Fax:
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Estimated Number To Attend:
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Purpose of the Event?
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Special Instructions:
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Sometimes convention centers require additional insured and will send this request in writing to
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the department requesting the certificate of insurance. If you receive anything like this it must
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accompany your request. This will help us get exactly what you need in the way of insurance
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to your for your event.
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Additional Insured:
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Jim Reed has requested that all contracts be E-MAILED to Jeannie Miller to be reviewed and
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signed by the Controller's office before execution of the contract and certificate of insurance is issued.
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NOTE: Requests must be received in the Controller's Office at least three - four weeks prior
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event in order for us to meet your requests in a timely manner. Any requests received later than
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that may result in problems obtaining the coverage you must have for your event. Plan ahead !
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For Accounting Use Only
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Approval:
Date:
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