Proof of Coverage Request - Synchrous

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Proof of Coverage Request

Request Proof of Coverage

Housing Authority or Insured Entity*
Effective Date*
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

For public entity related questions, please contact:

Rachel O’Neil

(360) 574-9035 x107

For tax credit / non-profit related questions, please contact:

Torey Plummer

(360) 574-9035 x103

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