Certificate Of Insurance Request Form Template printable pdf download

Certificate Of Insurance Request Form Template

Mercer Consumer

a service of Mercer Health &

Benefits Administration LLC

PO Box 14575

Des Moines, IA 50306

Phone: 1-800-503-9227

Optimist International Certificate of Insurance Request Form

Are you a current, active member of your organization?

Yes

***This Certificate request form is for professional individuals, clubs, and chapters.***

Club/Chapter Name:

Policy Number or Client Number

(

, Insurance Products, Optimist Club Liability,

Summary of Insurance

Name, Title, & Address of insured/Member Requesting Certificate:

Telephone Number:

Email Address:

How would you like the Certificate of Insurance sent to you?

Fax to:

Insured:

Certificate Holder:

Email to:

Insured:

Certificate Holder:

Mail to:

Insured:

Certificate Holder:

1. Name of event:

2. Location of the event (Name and Address):

3. Date of the event/function:

4. Name of entity (including mailing address) requesting proof of liability coverage:

PLEASE ADVISE IF ENTITY IS A CITY, COUNTY OR STATE ORGANIZATION

Yes

***

***IF THE LIMIT OF LIABILITY IS OUTSIDE THE NORMAL LIMITS (1/MIL PER OCCURRENCE/2MIL

PER AGGREGATE) PLEASE INDICATE HERE THE REQUIRED LIMITS._______________________

TALENT • HEALTH • RETIREMENT • INVESTMENTS

Certificate Of Insurance Request Form Template