Certificate of Insurance

School District

School District Name:
Certificate Holder Name:
Address:
City:
State:
Zip Code:
Phone:
Coverages Requested:	General Liability Auto Liability Excess Liability Property/Auto Phus Damage (please state value below) Workers' Compensation School Leaders Professional Liability Other
Add Certificate of Insurance Holder as:	Additional Insured Loss Payee
Description: (Include purpose of certificate)
Questions/Comments:
Requested By:
Email:

* = Required Field

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