CERTIFICATE OF LIABILITY INSURANCE REQUEST FORM

Please provide the information requested below and submit. All fields in Sections I and II are mandatory for submittal. Unless otherwise instructed ORM will mail the original Certificate of Liability Insurance directly to the Certificate Holder and a copy to you. If you have any questions please call 360-407-9199.

Section I - State Agency Information - Please fill in ALL information

Your Agency:

Your Name:
Your Phone:
Your Email:

Section II - Certificate Holder Information - Please fill in ALL information
(Information on the entity requiring the Certificate of Insurance)

Outside Entity:
*Please include all parties requested (ie: directors, officers, agents, employees, etc.)
"ATTN" Name:
Email:
Fax:
Address:
City:
State: Zip:
Reason for Certificate:
Date Certificate Needed:
IMPORTANT NOTE: If there is a written agreement related to this certificate have insurance requirements been reviewed? YES NO

Section III - Special Mailing Instructions
(Complete ONLY if you want the certificate of Insurance to be mailed to someone other than the Certificate Holder)

Name:
Address:
City:

State:

Zip:

Section IV - Other Special Instructions