INSTRUCTIONS FOR REQUESTING

PROOF OF INSURANCE

(When Diocesan Location needs to provide a certificate)

  1. To obtain a certificate of insurance you must complete the following “Certificate of Insurance request form”

and email or fax tothe noted address on the form.

  1. For any certificate that will requiredspecial wording (additional insured, waiver of subrogation, etc.)

you must submit a copy of the contract or insurance requirementsalong with the completed certificate of

insurance request form.

  1. Please include yourcontact information if we should need any clarifications.
  1. If you are utilizing any of the services listed below you should request a proof certificate of insurance

From the vendor providing:

Caterer
Bars
Taverns
Restaurant
Pub
Barbeque(BBQ)
Liquor being served/sold
DJ’s
Concerts
Musicians / Carnivals
Amusement
Entertainment
Mechanical Games
Rides
Bounce Houses
Trampolines
Inflatables
Festival
Fireworks
Fire(related)
Parade
Float(s) / Hotel
Motel
Resorts
Horses
Animals (any)
Piers
Beach(es)
Knights of Columbus
Boy Scouts
Girl Scouts / Tennis
Hunting
Fishing
Water Events
Boating
Skiing
Hot air balloons
Equestrian
Golf
Sport Teams / Cleaning Services
Lifts
Contractors
Vendors
Roofers

Certificate of insurance request form

DIOCESEOF / Orlando / Pensacola-Tallahassee
St. Augustine / Venice
Requested by:
Contact Name:
Phone: / Email:
Named insured : Diocesan entity/Church or school
Complete name:
Address:
City: / Zip Code:
Email: / Phone: / Fax:
Coverages needed(Only check the applicable options)
/ GL / / Property / / Fidelity
/ WC / / Business Property( for Contents/Rental or leasing of equipment including theft) / / E&O
/ Auto / / Builders Risk / / Other
Certificate Holder : entity asking for the insurance
Complete name:
Address:
City: / Zip Code:
Email: / Phone: / Fax:
Special interest: ( Please attach a copy of one of the following if available: insurance requirement, contract agreement, lease contract)
/ Proof of Insurance
/ Additional Insured (if you are required by agreement)
/ Waiver of Subrogation
/ Loss Payee (if you are required by agreement)
/ Other
Remarks: Please provide any details describing the purpose of this certificate (E.g. value of equipment, serial number, event type and date(s), contract number, etc.)
Delivery distribution:
U.S. Postal Service / Email address / Fax No.
Named insured: /
Certificate holder: /
Other:______/
Other:______/
Please forward completed request form to: Arthur J. GallagherRMS, Inc.(Miami)
Via email:1) Or 2) via fax: 305-716-3293
Processing time, please check: ____ Standard 48 hours upon receipt
____ Rush(if event will occur in less than 24 hrs.)
If you may have any questions, please contact: Religious Team at 305-592-6080 Or 1-800-488-3003