Certificate Request | Archdiocese of Baltimore

Your Information

Name:*

Email Address:*

Name of Parish/School/ACC Program:*

Your Phone Number:*

Fax Number:

Parish/School/ACC Program Address:*

Parish/School/ACC Program City:*

State:

Zip:

Certificate Holder Information (Third Party Entity requesting proof of insurance)

Certificate Holder Name:*

Certificate Holder Address:*

Certificate Holder City:*

State:

Zip:

Certificate Holder E-mail:

Certificate Holder Fax Number:

Period for which coverage is required:

Start

End

Certificate Information

Need By:

Certificate Type:*

Property Certificate

Liability Certificate

Auto Certificate

I'm not sure

Invalid value

Choose Property certificate for property loss payees and mortgagees. Select Laibility certificate for the owner of a facility/land you want to use. or participatein. Additional Insured status required by contract or agreement. Auto certificate for leases and auto loans.

Description:

Description of Off-Premises event or property/auto/location. Include account and/or lease numbers.

Specifics:

Evidence Of Insurance Only

Loss Payee

Mortgagee

Additional Insured

Special Instructions:

Attachments:*

Fax

None

Please indicate how you plan on forwarding additional information to the Archdiocese regarding this request.

Important Note:

If additional insured status is being requested the contract/agreement needs to be either faxed to 410-547-3153 or scanned and e-mailed directly to riskmanagement@archbalt.org by clicking Here

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Certificate of Insurance Request Form