Leave this field blank Organization Name Street Address City, State, Zip First and Last Name Job Title Your role in the organization Email address Phone Number Certificate Holder Information (optional) Certificate Holder Name Certificate Holder Address Certificate Holder City, State, Zip Attention: Certificate Holder Email (optional) Certificate Holder to be named: (optional) Additional Insured Yes No Loss Payee Yes No Evidence of Property Insurance Yes No Landlord Yes No Mortgagee Yes No Ongoing? Yes No Reason for Certificate Description of activity or property address Description of Activities If camp/retreat, please list the activities you will be participating in. If the Event is a Camp" (optional) Who is running/supervising the activities? Dates, Number of participants, Equipment Special instructions (optional) Upload a file (optional) Be secure! Please do not upload sensitive information: financial, medical, social security or password data. Choose file Uploading… (0%) Browse Oops. This file type isn’t allowed. This file size is too big.