Editing previous response:

Please fix the highlighted areas below before submitting.

Certificate of Insurance Request Form

ALLIANT LOGO
REQUEST FOR CERTIFICATE OF INSURANCE AND ENDORSEMENTS FORM

Department requestiong certificate informatoin please complete the form below.

Required fields marked with an asterisk *

Name of Dept:*

Answer Required

DATE:*

Answer Required

Contact Information

HBUHSD Rep Requesting Cerificate*

Answer Required

Email Address*

Answer Required

Phone number or Extension*

Answer Required

COVERAGES REQUESTED

General Liability Amount Requested*

Answer Required

Professional E&O Liability Amount Requested

Answer Required

Workers' Comp Amount Requested

Answer Required

Auto Liability Amount Requested

Answer Required

Sexual Abuse & Molestation Amount Requested

Answer Required

Other - Description & Amount Requested

Answer Required

CERTIFICATE HOLDER INFORMATON

NAME:*

Answer Required

ADDRESS*

Answer Required

CITY, STATE, ZIP*

Answer Required

PHONE*

Number Required

EVENT/CONTRACT INFORMATION

Description of Event/Contract (description to be added to the certificate of insurance, if no description is provided, a description from the contract will be used.)

Answer Required

A COPY OF CONTRACT/AGREEMENT OR USE PERMIT MUST BE ATTACHED.

Answer Required

Choose a file or drag it here.

ENDORSEMENT INFORMATOIN

Answer Required

ADDITIONAL COVERED PARTY

WAIVER OF SUBROGATION

LOSS PAYEE

HOLD HARMLESS

SPECIFIC WORDING FOR ADDITIONAL COVERED PARTY

Answer Required

Confirmation Email

Confirmation Email *

Email Required