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 EndorsementWhich 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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. CAPTCHAPhoneThis 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