Certificate/evidence Of Insurance Request Form
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1Certificate/Evidence of Insurance Request Form
Email to CertRequests@AJG.com
Gallagher SKS
Date of Request:
Requested By:
Servicing Office Location:
(Cincinnati)
Cert #
NEW
RUSH
REISSUE
Request Type:
Primary Named Insured: Trail Life (TRAILIF‐01)
Named Insured to be shown on the certificate:
Youth Adventure Programs Inc. dba Trail Life
Name:
4853 South Orange Ave STE C
Street Address:
Orlando, FL 32806
City, Zip & State:
Certificate Holder:
Check box if this cert is to be issued on a one time only basis and does not need to be renewed
Name:
Additional Name:
Attention:
Street Address:
City, Zip & State:
Cert Delivery
Email:
Fax:
US Mail
Coverage (Check the boxes that apply)
Waiver of
Coverage
Additional Insured
Loss Payee
Mortgagee
Subrogation
General Liability
Auto Liability
Auto Physical Damage
Workers Compensation
Limits: 5,000,000
Umbrella/Excess
Property
Description (operations/location/vehicles):
Relevant Contract Documents with Insurance Provisions attached?
Yes
No
Any other comments or delivery instructions:
13‐14 Troop Master Template
Arthur J. Gallagher & Co. SKS. 1 W. 4th Street, Ste 1300, Cincinnati, OH 45202
Pg. 1 of 1
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Parent category: Business