CERTIFICATE OF INSURANCE - REQUEST

							CERTIFICATE OF INSURANCE - REQUEST
YOUR ORGANIZATION NAME Organization: Person Requesting: Do you need a copy sent to you? FAX Number: Yes Contact Phone: No Email:

Date: WHO NEEDS THE CERTIFICATE? (Facility requesting your information.)
Name of Organization: Contact Name: Address: City: FAX: DESCRIPTION OF EVENT: DATE OF EVENT: EMAIL ADDRESS: WHAT INSURANCE DO THEY REQUIRE? General Liability Professional Liability Special Events Umbrella Auto Other CHECK IF FOR REGULAR MEETINGS: State: ZIP: Date Certificate Needed:

SPECIAL WORDING REQUIRED

PLEASE FAX / EMAIL TO: Michelle Hooper michelleh@ilselectrisk.com FAX 630/836-8679