Certificate of Insurance: Request to Agent
Fill in every bracket and send this to your agent or broker. Attach the venue’s requirements sheet or contract page if you have one. It answers most of the questions below better than you can paraphrase them.
This template is general information, not legal advice. What a document like this can and cannot do varies by state, so have a local attorney review your final version before you use it.
1. Send to
Agent or broker: [name] · [agency].
Email: [email] · Phone: [phone].
Subject line to use: Certificate request · [your business name] · event [date] · needed by [date].
2. From (the insured)
Named insured, exactly as it appears on the policy: [legal business name].
DBA, if the venue knows you by a different name: [trading name].
Mailing address: [address].
Contact for this request: [name] · [phone] · [email].
Policy number(s): [general liability policy number]. [Other policies, if the venue asks for them: commercial auto, umbrella, workers’ compensation.]
Policy period: [start] to [end].
3. What I am asking for
Please issue a certificate of insurance evidencing the coverage below for the event described in Section 5, and send it to me, and, if you send it directly, to the certificate holder in Section 4.
I need it by: [date]. The event is on: [date].
Number of certificates needed: [count]. [Some venues want one for the park and one for the city.]
4. Certificate holder
Copy this from the venue’s requirements sheet, character for character. A certificate naming the wrong entity gets rejected and you start again.
Certificate holder legal name: [exact legal name].
Address: [street] · [city, state ZIP].
Attention / department: [name or department].
Their reference for this event, if they gave one: [permit or reference number].
5. Event and operations covered
Event name: [name]. Date(s): [date(s)]. Hours: [start] to [end].
Location: [venue name] · [full address].
Description of operations, as the venue words it if they specified one: [for example, delivery, setup, supervision, and removal of inflatable amusement equipment].
Units on site: [names and count]. Attendant provided: [yes · no].
Estimated attendance, if the venue asks: [number].
6. Limits requested
Copy these from the venue’s requirements sheet. Do not state a limit you have not confirmed with your agent. A certificate showing coverage you do not carry is a problem for you, not for the venue.
General liability, each occurrence: $[amount as required].
General aggregate: $[amount as required].
Products and completed operations aggregate: $[amount as required].
Damage to premises rented: $[amount as required].
[Any other coverage the venue lists: commercial auto, umbrella or excess, workers’ compensation, abuse and molestation: $[amounts as required].]
If my current limits are below anything above, please tell me what it would cost to raise them for this policy period rather than issuing a certificate that does not meet the requirement.
7. Additional insured and special wording
Attorney review recommended
CONFIRM THIS SECTION WITH YOUR AGENT BEFORE YOU PROMISE IT TO THE VENUE, and have your attorney read the venue’s contract clause if one is attached. A certificate EVIDENCES a policy; it does not create coverage. Additional-insured status, waiver of subrogation, and primary-and-non-contributory wording are policy ENDORSEMENTS: your agent may need to add them, they may carry a premium, and the carrier may decline. Asking for them on a certificate that the policy does not actually carry is the most common way this goes wrong.
Additional insured requested: [yes · no]. If yes, name them exactly as the venue writes it: [exact legal name(s)].
Basis requested by the venue: [ongoing operations · ongoing and completed operations · as their contract requires; quote it].
Waiver of subrogation requested: [yes · no].
Primary and non-contributory wording requested: [yes · no].
Notice of cancellation requested: [days, as the venue requires].
Any other wording the venue demands, quoted verbatim from their document: [paste it here].
Please confirm which of the above the policy already carries, which need an endorsement, and what any endorsement costs, before the certificate goes out.
8. Delivery
Send the certificate to: [your email].
Also send directly to the certificate holder: [yes · no]. If yes: [their email or portal].
The venue requires submission through a portal: [yes · no]. If yes: [portal name and link].
Please copy [name] at [email] on the issued certificate.
9. Sign-off
Thank you. If anything above is unclear or cannot be issued as requested, please call me at [phone] rather than sending a certificate that will be rejected.
Requested by: ______________________ Date: __________
[Your name] · [title] · [business name]