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Request for Certificate of Insurance

Please scroll down and complete the form below

Today's Date:
Preparer's Name:
   
REQUESTOR'S INFORMATION
Name:
   
Address:
City
State
Zip Code:
   
Daytime Phone:
Fax:
   
Caller's Title:
   
Church Unit:
(Ward & stake or corporation sponsoring activity)
   
ACTIVITY INFORMATION or LEASE DATES
   
Activity (Specifics of activity; if rental propery, need serial #'s of equipment):
   
Activity Period & Times
From (Starting time/date):
To (Ending time/date):
   
Specifics:
   
Name of Location:
   
Address:
City:
State:
Zip Code:
   
Additional Comments, Notes, Specifics If Using A Portion Of Building:
   
LEGAL ENTITY REQUIRING CERTIFICATE
   
Name of Certificate Holder:
(This can be the certificate holder or someone else in the organization)
   
Address:
City:
State:
Zip Code:
   
Attention To:
Phone Number:
Fax:
   
LIABILITY LIMITS (General Liability, auto, property, WC, etc. Must have value of property if property ins. is needed)
Dollar Requirements: $
   
   
Risk Management Links
Workers' Compensation
TDI
Points of Interest
Sexual Harassment

Risk Management Forms
Vehicle Accident Investigation Form
Witness Statement Form
Employee Accident Report
Facts of Accident
TDI
BYUH Property-Loss Claim Form
NONBYUH Property-Loss Claim Form
BYUH Building & Structures Loss-Claim Form
BYUH Report for Nonwork-Related Injuries
Request For Certificate of Insurance