Pullen Insurance Services

 

Certificate of Insurance Request Form

The certificate of insurance request form should be used to request additional certificates of insurance evidencing insurance coverage for your organization’s activities. Online request will only be processed if this form is completed by an authorized official of the sports organization on file with Pullen Insurance Services.

1.	Name of sports organization (as it appears on your certificate of insurance):
2.	Policy number (as it appears on your certificate of insurance):
3.	Mailing Address:
	City, State, Zip:
4.	Name of person completing the request:
5.	Title of person completing the request:
6.	Email Address:
7.	Phone Number:
Please complete the below for each certificate request:
	Name of Certificate Holder:
	Mailing Address:
	City, State, Zip:
	Relationship to you:	Owner/Landlord of Facility Sponsor Other

	If other, please explain:
	Special certificate language needed?

Please remember to verify your requests as specified in any contracts you have signed with a landlord prior to submitting your request for approval and processing.

 

I herby confirm I am an official of the above sports organization and I am authorized to request certificates of insurance on behalf of the organization.	I hereby confirm.
I understand requests will take up to 24 hours to process. All certificates of insurance will be delivered to the sports organization contact only and Pullen Insurance Services will not send the certificates directly to the certificate holder (i.e. property owner).	I understand.