Request for Certificate of Insurance

Staff member filling out requestrequired

Email Address

Please choose the District needing a Certificate of Insurancerequired

Dresden School District

Hanover School District

Norwich School District

Certificate Holder:required

Vendor/Company requesting certificate

Certificate Holder Contact:required

Certificate Holder Address:required

City/State/Zip:required

Evidence of Coverage Requested by Certificate Holder:requiredAt least one type of insurance is required

General Liability

Automobile

Workers' Compensation

Property (Value required if checked)

Loss Payee (property owned by others)

Professional Liability (explanation required if PL is checked.)

At least one type of insurance is required

If information is required in Evidence section above, please add information here:

Description

Provide brief description of project, event, lease, dates, etc. pertaining to certificate.

Additional Covered Party (Liability)

Extension of Coverage to an Additional Covered Party will require contract review and approval by BA

File Upload for Contracts

Attach up to 1 file with a maximum size of 10MB

No file chosen

Please send Certificate of Coverage to Certificate Holder via:Please select up to 3 choices

Email Address

Fax Number

Mail Certificate to Certificate Holder at the address listed above.

Please select up to 3 choices

Provide Email address or Fax number for certificate:

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