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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