Proof of Coverage Request

Request Proof of Coverage

Company
This field is for validation purposes and should be left unchanged.
Housing Authority or Insured Entity*
Effective Date*
Your name*
First Last
Your email*
Your phone*
Proof of Coverage requested*
Select all of which you need proof
- Liability
- Excess Liability
- Property
- Terrorism
- Errors & Omissions (E&O)
- Fidelity
- Hired & Non-Owned Auto
- Auto
Do you require a:*
- Certificate AND Endorsement
- Certificate (Only)
Certificate and Endorsement
Which of the following do you require?
- Name certificate holder as Loss Payee (for Property)
- Name certificate holder as Mortgagee (for Property)
- Name certificate holder as Lender’s Loss Payable (for Property)
- Name certificate holder as Additional Insured (for Liability)
- Add 30-day cancellation clause
AS RESPECTS:
(property location and address, event, administration of program contract, other):
Is this an EVENT?*
- YES
- NO
Date of Event
Location of Event
Activities of the Event
Is this a PROGRAM CONTRACT?*
- YES
- NO
What is the Purpose of Contract?
What are the Responsibilities of the Insured?
Does the certificate holder require specific wording on the certificate, grant, and/or loan number?*
- YES
- NO
If YES, what is the wording?
Certificate Holder Name*
Certificate Holder Address*
Street Address Address Line 2 City State ZIP Code
ELECTRONIC SIGNATURE*
- I certify that the information on the application is true and accurate to the best of my knowledge. I understand that if alternate information becomes available, it may result in a change of premium or policy/coverage cancellation. By submitting I am providing my electronic signature.

Questions?

For questions about proof of coverage, contact the representative assigned to your organization, based on the first letter of your member or affiliate member name.

Names beginning A–N

Jen Polanco

(360) 574-9384

Names beginning O–Z

Meaghan Brown

(360)718-5699