MIAMI VALLEY RISK MANAGEMENT ASSOCIATION

CERTIFICATE OF INSURANCE/COVERAGE REQUEST FORM

(Please allow 3 working days, whenever possible)

Date Requested:      ________________________                    Requested By:      ____________________________

Date Needed:          ________________________                    Telephone #:     ______________________________

                                                                                                    FAX #:        ________________________________

Requesting Member:     __________________________________________________________________________

Certificate Holder:        Name:    ___________________________________________________________________

                                    Address:  __________________________________________________________________

                                    Attn:   _____________________________________________________________________

                                    FAX #: (if necessary) _________________________________________________________

Reference/Purpose: (Why is the certificate needed?) (Please include date of event, location, lease or contract #, etc. and any written request received from certificate holder.)

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Coverage Requested:                                                            Specific Limits:

General Liability _____                                                             __________________________________________

Auto Liability  _____                                                                __________________________________________

Property  _____                                                                       __________________________________________

Auto Physical Damage  _____                                                  __________________________________________

Loss Payee Status Requested:                    [     ] Yes                [     ] No

Additional Insured Status Requested          [     ] Yes                [     ] No

Important:     Do not offer to provide additional insured unless requested and absolutely necessary.  Staff will review and make determination on all requests for additional insured status.

Special Instructions or Requests:

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Fax the completed form to the MVRMA Office

Phone: 937/438-8878        FAX: 937/438-8330