OFM, Risk Management Division - Certificate of Insurance Request Form, Lease/Purchase Programs

CERTIFICATE OF INSURANCE REQUEST — LEASE/PURCHASE PROGRAM

This Form is for Lease/Purchase programs only. Once the form is submitted, it will send the information you enter to ORM for processing. If you have any questions or problems, please contact ORM customer services at 360.902.7303.

(fields with an asterisk (*) are required)

*Agency:

Date:

Requestor Information:

*Name:

*Phone:

Fax:

Email:

Contract Information:

*Contract #:

*Location of Equipment:
(street address)

*City:

*State:
  *Zip Code:

Equipment Description $ Value

Proof of Insurance:

Liability Coverage:
     provided by the state's Self Insurance Liability Program

Property Damage Coverage:

Retain the risk (accept financial responsibility for property damage)
    or
Add equipment to the state's master property policy

Comments:

*Agency:
Date:
Requestor Information:
*Name:
*Phone:
Fax:
Email:
Contract Information:
*Contract #:
*Location of Equipment:	(street address)
*City:
*State:	*Zip Code:
Equipment Description		$ Value





Proof of Insurance:
Liability Coverage: provided by the state's Self Insurance Liability Program
Property Damage Coverage:
Retain the risk (accept financial responsibility for property damage) or Add equipment to the state's master property policy Comments: