Church & Casualty Insurance Agency

 

 

 

Request for Certificate of Insurance

Please Note: Completion of this form does not automatically grant issuance. Underwriting approval and/or additional info may be necessary. We also encourage you to review any contracts with an attorney prior to entering into an agreement with another organization.

Your certificate will be issued within 2 business days of receipt If your request requires verification or special wording please allow 5 business days turnaround time from the date complete information is received. Please note we cannot guarantee rush requests. Thank You.

*Required Fields

 
Account or Customer Number:
*Name (Person completing this form):
*Organization Name:
What's this?
*Mailing Address:
*City:
*State:   CA
*ZIP:
*Phone:
*Fax:
*E-mail Address:
*Event Description:
(Please provide as much detail as possible) What's this?
*Event Date:
*Event Frequency:
(If this is a recurring activity a charge may be assessed) What's this?
One Time
Periodic
*Event Location:

CERTIFICATE HOLDER
*Certificate Holder Name:
What's this?
*Certificate Holder Address:
*City:
*State:
*ZIP:
*Certificate Holder Fax:
What's this?
*Certificate Holder E-mail Address:
*Deliver to Certificate Holder by:
Mail
Fax
Email
*Does the certificate holder require special coverage such as to be named additional insured?:
What's this?
Yes No
*Indicate status of Certificate Holder:
Facility Owner
Event Sponsor
Vendor
Lessor
Other
*Has the organization entered into any contract or permit relating to this event?:
What's this?
Yes No
*Certificate required by (date):
*Additional instructions, remarks or comments:

Please make sure all form fields have been completed before submitting.

   © Copyright 2005. Church & Casualty Insurance Agency. All rights reserved.