Service Request Certificate - Academic Health Plan

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Certificate Request Form

* fields are mandatory

Current Information

*Named insured :

*Policy number:

Contact first name:

Contact last name:

Phone number:

Fax number:

E-Mail:

Certificate of insurance request

*This certificate is for our:

Program coverage (commercial general liability) Equipments & contents coverage

*Check the type of certificate you are requesting: (what's this?)

Additional insured	Evidence of coverage	Loss payee (Inland Marine/Equipments & Contents)

Certificate holder information

Entity name (as it should appear in the certificate):

Mailing address:

City:

State:

Zip

*Relationship to insured entity:

Owner/lessor of premises	Sponsor	Co-promoter	Mortgagee	Franchisor
Event Organizer	Lessor of Equipments and Contents
Other (please identify/explain)	Invalid Characters
Please enter field

If applicable
Invalid Characters

Dates of events/activity:

From

Hours of events/activity:

From

Types of events/activity:

Name of events/activity:

Location of events/activity:

Need by date:

Special certificate language needed (please explain):

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Document Delivery

This certificate will be delivered based on the option you indicate below.

E-mail to:		Attn:	Invalid Characters
	Invalid email ID entered. Please enter field
Fax to:		Attn:	Invalid Characters
	Please enter field
Mail to:		Attn:	Invalid Characters
Mailing address:	Please enter field Invalid Characters
	Invalid Characters
City:	Please enter field Invalid Characters
State:	Please select
Zip:	Please enter field