Dance Insurance - K&K Insurance Brokers, Inc Canada.

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Certificate Request Form

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Current Information

*Named insured :

*Policy number:

Contact first name:

Contact last name:

Phone number:

Fax number:

E-Mail:

Certificate of insurance request

*This certificate is for our:

Program coverage (commercial general liability) Equipments & contents coverage

*Check the type of certificate you are requesting: (what's this?)

Additional insured	Evidence of coverage	Loss payee (Inland Marine/Equipments & Contents)

Certificate holder information

Entity name (as it should appear in the certificate):

Mailing address:

City:

Province:

Postal Code:

*Relationship to insured entity:

Owner/lessor of premises	Sponsor	Co-promoter	Mortgagee	Franchisor
Event Organizer	Lessor of Equipments and Contents
Other (please identify/explain)	Invalid Characters
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If applicable

Dates of events/activity:

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Hours of events/activity:

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Types of events/activity:

Name of events/activity:

Location of events/activity:

Need by date:

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K&K Insurance Brokers, Inc. Canada