CERTIFICATE OF INSURANCE REQUEST FORM

If you are required to provide a Certificate of Insurance to a vendor, contractor, or other entity for any reason, please supply the following information and send this form to either Lori Prinz or Ashley Orologio.

PLEASE INCLUDE A COPY OF THE CONTRACT, FLYER or SECTIONS relating to insurance, indemnification and/or

hold harmlessagreements with this form.

Your Name
	Your Position
	
Your Class or Grade Level
	Your e-mail
	
Your Telephone Number
	Your Fax Number
	
Name of Certificate Holder (i.e. Entity requesting the certificate)
	
Address of Certificate Holder
	
Description of Activity: For events, activities, and performances include the date(s), time(s), and location of the event or activity.

Please be sure to attach a copy of the signed contract, flyer or paper describing the event if you received one.