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Colorado Farmers’ Market Association
Certificate Request 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 and/or email address:

Additional Insured Certificate Holder
Name of Company/Municipality/or other entity:
Attn:
Address:
City/State:
Zip code:

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 Certificate Holder 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): _______________________________________________________________________
_______________________________________________________________________

Does the additional insured require that a Certificate be sent directly to them by the insurance company?
Fax Number to send certificate to:
or
Email address to send certificate to:

Any other special provisions:

sbh/2-10-08

Colorado Farmers' Market Association © 2008