Certificate Of Insurance Request Form
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1Complete and mail or fax to:
Alliant Insurance Services, Inc.
4530 Walney Road, Suite 200
Chantilly, VA 20151
(800) 298-7373 / (703) 397-0995 Fax
E-mail:
Certificate of Insurance Request
Contact Information
Organization name:
Date:
Mailing address:
City:
State:
ZIP Code:
Contact name:
Email:
Phone:
Fax:
Items Required (check all that apply)
Certificate of Insurance (proof of insurance)
Additional Insured Requested (attach any additional instructions)
Special Form Required (attach form)
Reason Certificate Requested
For owner of land; include address/location of land
For a municipality
For an event site owner
Event name:
Estimated number of people attending:
Dates:
Your organization will be:
Main sponsor
Co-sponsor
Vendor
Grant or other:
Certificate Holder/Additional Insured (if requested)
Name and mailing address of person or organization that requested proof of insurance from you:
Holder name:
Address:
City:
State:
ZIP Code:
Attention:
Email:
Fax:
Events Covered
The following events are covered when attendance is less than 500: meetings and seminars; picnics and dinners;
festivals and concerts; bike races and treks; foot races and treks; auctions; and golf tournaments.
Complete a Special Event Coverage application to receive a quotation for coverage if your planned event falls
outside these parameters (greater than 500 or not on the above list).
Rev. 6/09
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Parent category: Business