Insurance Certificate Request

Use this form to request a COI or additional insured. Your request will be received and routed to insurance through the Support Center.

Venue Information

Venue Name

Address Line 1

Address Line 2

City

State

Postal Code

Is this request for a program?

Select the Travel Unit

Travel Unit

Is this request for a site, vehicle usage, or both?

Need Proof of Insurance?

Need Additional Insured?

Please upload a copy of the rental agreement or building usage form stating the school's need for an additionally insured certificate.

What LifeWise Program is this for?

Name of Person Submitting Request

Email of Person Submitting Request

Other comments or info: