DISTRICT:



SEND REQUEST TO:

|Servicing Agent Name | |

|Email / Fax Number | |

REQUESTED BY:

|Your Name | |

|Name of District / CS / COE | |

CERTIFICATE HOLDER: Entity requesting the Certificate of Insurance

|Classification of Certificate Holder | |

| |Property/Facility Owner Bank/Lender Contract for Services |

| | |

| |Field Trip Venue ROP/Internship Employer Grant Funding |

| | |

| |Other (describe) _____________________________________________ |

|Name of Certificate Holder | |

|Mailing Address | |

| | |

|How would you like the certificate delivered to the | |

|certificate holder? |Mail to address above. Email to ______________________________ |

| |FAX to ___________________ Attention: __________________________ |

| |Note: An email copy will automatically be sent to your office. |

WHY IS THIS CERTIFICATE BEING REQUESTED? Complete applicable section.

|Field Trip or |Description of class/student group and school they represent| |

|Student Club |(ex. 3rd grade class or cheerleaders from ABC School). | |

|Activity | | |

| |Type of activity (field trip to where, music/drama | |

| |performance, car wash, name of fundraiser, etc.) | |

| |Date(s) | |

| |Is this school sponsored & supervised? | YES NO |

| | Attach a copy of any written request / use agreement. This is mandatory if the certificate holder is requesting to be named as an |

| |“additional insured.” All agreements should be in the District/COE/CS name (not site) and signed by an authorized official. |

|Parent Club, Booster|Is this event / activity sponsored by a PTO/Booster/Foundation? YES NO |

|or Foundation |These activities are not covered by NCSIG. Refer to website for coverage options. |

|Activity |(Parent Booster Groups Tab) |

|Loan or Lease |Purchase of equipment, bank loan, financing, etc. |

|Agreement |Attach a copy of the agreement and/or insurance terms including the agreement number. |

|Contract for | Attach a copy of the contract. This will provide contract dates, agreement #, parties to the contract, insurance terms, etc. |

|Services | |

|ROP | Attach a copy of an agreement if additional insured wording is required. |

|Internship |No agreement, use standard ROP wording. |

|Other | |

| | |

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