Certificate of Insurance Request

Please allow a 2 week minimum for Certificate Holder requests and a 30 day minimum for Named Insured requests.
Event:
Event Date:
Event Times:
Jurisdiction:
Chapter Name:
Name of Venue:
Address:
City/State/Zip:
Food or Beverage:
- Served
- Sold
If sold what kind:
Number of DeMolay:
Number of Advisors:
Choose One*
- Certificate Holder
- Named Additional Insured
Certificate Holder is simply proof of insurance, where as Additional Insured status gives coverage and rights under your sub-contractors policy.
Name of Additional Insured Entity:*
Address:*
Addl Address:
City,State,Zip:*
Name:*
Address:*
Addl Address:
City,State,Zip:*
Send Completed Certificate
- Email Certificate
- Mail Certificate
Email To:
Mail To:
Address:
City,State,Zip
Special Instructions:
Additional Emails
Additional Emails
Additional Emails
Additional Information
Max. file size: 128 MB.

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