MCCCD Legal Services Department - Request for Certificate of Insurance

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Request for Certificate of Insurance

*Requester:**	Name: E-mail: Phone: A copy of the certificate will be sent to the e-mail address listed above. An original will be mailed to the certificate holder.*
*College:**	CGCC DSSC EMCC GCC GWCC MCC MSC PVCC PC RSC SMCC SCC
*Need By:**
*Term:**	Start Date: End Date: (End date must be 11/01/08 or before) Do you need the certificate renewed on an annual basis? Yes No
Certificate Holder* (Name and Complete Address of Party Requesting Certificate)	Would you like us to e-mail a copy to the certificate holder? If so, please provide an e-mail address: Does certificate holder need to be named as an additional insured? Yes No
Reason for Certificate* (Job/Event Description, Contract, etc.)
*Coverages and Coverage Limits:**	General Liability Automobile Liability Educators Legal Workers' Compensation Other :
Special Instructions:

* Required Field

The original certificate will be mailed to the Certificate Holder unless otherwise specified under Special Instructions. A copy will be retained on file in Risk Management.

For questions concerning insurance certificates, contact Risk Management at 480-731-8157; 480-731-8890 (fax).

Please make sure the required fields are completed BEFORE submitting.

Questions or comments?
Contact Ruth Unks @ 480.731.8879

Office of General Counsel
2411 West 14th Street
Tempe, AZ 85281-6942
480.731.8877 / 480.731.8890 fax

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Page Updated 10/30/07