Form - Certificate of Coverage - Client Documents Portal

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Date(Required)
MM slash DD slash YYYY
Type of Certificate of Coverage Request
Please select all coverages that apply. Use the SHIFT button to select more than one option.
Entity Name Requesting Certificate(Required)
Group or JPA Coverage Entity Name:
Name(Required)
First Last
Phone
Email(Required)
Address
Street Address City State / Province / Region ZIP / Postal Code
Name of Certificate Holder(Required)
Certificate Holder Address(Required)
Street Address City State / Province / Region ZIP / Postal Code
Certificate Holder Contact(Required)
First Last
Email
Phone
Fax
Description of event or activity for which coverage is being requested:(Required)
Begin date of event or activity(Required)
MM slash DD slash YYYY
End date of event or activity(Required)
MM slash DD slash YYYY
Limits of Liability being requested(Required)
Additional Covered Party?
If there is an additional party being covered, please provide documentation such as a contract or lease agreement which clearly indicates the insurance requirements
- Yes
- No
Waiver of Subrogation Requested (Workers' Compensation only)(Required)
If there is a waiver of subrogation, please provide documentation such as a contract which clearly indicates the insurance requirements.
- Yes
- No
Is Property Coverage being requested?
- Yes
- No
Total Value of Property Coverage being requested (amount required if Yes)
Is Loss Payee Required? (Property only)
- Yes
- No
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