Certificate of Coverage Request Form Use this form to request a Certificate of Coverage Certificate of Coverage (COC) Request Form Contact InformationMunicipality requesting COC:*Brigham CityCedar CityCentervilleDraperEnterpriseFarmingtonKanabLaytonMapletonOgdenOremPark CitySpanish ForkWest BountifulWest ValleyContact Name:* First Last Contact Email address:* Contact Phone Number:*The best number to contact you if we have questions.Certificate InformationName of Entity Requesting Certificate:*Those wishing to be listed as the Certificate Holder (i.e. UDOT, Zions Bank etc.)Address of Entity Requesting Certificate:*Address of the Certificate Holder Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purpose of coverage:*Please include name of event, description of activity.Dates of requested coverage:*Please include dates that coverage is requested.Does the certificate holder need to be listed as Additional Insured? Yes No Additional Information/Instructions:Please enter any additional information/instructions hereFile Upload:Please upload any documents associated with the request for Certificate of Liability Coverage here: Drop files here or Select files Max. file size: 100 MB. Additional Persons Requesting Copy of CertificateInclude anyone that would like a copy of the Certificate emailed to them. Name: First Last Email: Name: First Last Email: Name: First Last Email: CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
