Certificate of Insurance Request
New Procedures:
If you are in need of a Certificate for an event for your Non-Profit/Church, please see instructions below:
Please complete in detail and click submit button below - it will be sent to certificate@melhimesinsurance.com
Be advised that the MORE Information that is given to us, the quicker your request can be processed. Some requests MAY have to have Company Underwriter approval as YOUR Policy MAY not cover some 'activities'.
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Non-Profit/Church Name *
Policy Number *
Reason for the Certificate Request *
Description of ALL events/operations/special provisions *
Location of the Event - address *
Approximate Number of People Attending Event
What will be happening at the event (Picnic, Bar-B-Que, Bounce House, Rock Climbing, Water Slide)
Date(s) of the Event *
MM
/
DD
/
YYYY
Time of the Event
Time
:
Certificate Holder name, address, city, state, zip, phone, fax, email *
Does the Certificate Holder want to be named as an 'additional insured'? *
Email or Fax Number to send Certificate *
Person Completing this Form *
Thank You - Need Help? Call Mel Himes & Associates Insurance Agency at             800-329-3031 for the Processing Department
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