Certificate of Insurance Request

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Direct questions to: Traci Zuk: [email protected] or 224-366-1621

Date*
MM slash DD slash YYYY
ARCHOFC-01*
- Yes
Be sure to mark the circle next to yes – it is a required field.
Your Name*
First Last
Your Parish/School/Entity*
Your Email*
Your Phone*
Name of Organization/Business requesting certificate*
Address of Organization Requesting Certificate*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What type of Certificate is being requested?*
- Certificate of Liability Insurance
- Certificate of Property Insurance
- Unsure of what type is needed
Name of Function/Event
Description of Function/Event
Location of Function/Event
Date Function/Event is to begin
MM slash DD slash YYYY
Date Function/Event is to end
MM slash DD slash YYYY
Will alcohol be served at the Function/Event?
- Yes
- No
Are there special requirements to be included on Certificate? For example does an additional insured or a loss payee need to be listed? If so please provide details:
Description of property if applicable, please provide make, model serial #, lease#, loan#

Direct Questions to:

Director of Benefits & Risk Management

513.263.3354