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Colorado Farmers' Market Association Insurance

2009 Certificate Request Form for an Additional Insured

Please complete one form for each Additional Insured.

Date of Request:

Named Insured (Market Name):

Market Contact (Person to call or email if the insurance company has questions)

Name:

Phone:

Email address:

Additional Insured Certificate Holder

Name of Company/Municipality/or other entity:

Attn:

Address:

City/State and Zip code:

Phone:

Email address:

A standard Certificate of Insurance will be issued. If your request requires special wording, please indicate below and complete the following questions.

Special wording for Certificate Holder (Standard Certificate will usually list the name of the Additional Insured, the market's name in parentheses, and market's address. If the Additional Insured wants their address, and/or specification for their employees or affiliates on the certificate, please include the exact wording they require here): _______________________________________________________________________

__________________________________________________________________________________________________________

Special wording for Description of Operations (Standard Certificate indicates Seasonal Farmers Markets' and name of issuing insurance company): _______________________________________________________________________

_______________________________________________________________________

Certificates of Insurance will be mailed to the market. If the Additional Insured requires that an original certificate be sent to them by the insurance company, please indicate below.

Fax Number to send certificate to:

or

Email address to send certificate to:

Any other special provisions:

sbh/1-29-09

Colorado Farmers' Market Association © 2009