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Get and Sign Certificate Insurance Request Form Health
Event (name & address):
7. Date of the event(s):
8a. Name & address of entity requesting proof of coverage:
8b. Is the entity requesting to be named as an additional insured? Yes
8c. Does the entity own the event location?
Yes
8d. Explain the additional insured's role/interest in the event:
No
No
9. Type of event(meeting, musical performance, etc):
10. Explain your role/activities with respects to this event.
Signature:
Please fax or email your request to:
Fax: 515-365-3005
Email:...
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