Certificate of Insurance Request - Novick Group, Inc.

INFORMATION ABOUT YOUINSURANCE CERTIFICATE REQUEST FORMPlease complete a separate form for each required certificate.Insured Name: ________________________________________________________________________________Address: ____________________________________________________________________________________City: ________________________________________________ State: _______________ Zip ______________Phone: ______________________________________________ Fax:___________________________________Email: ______________________________________________________________________________________Person Completing this Form (Please print): _________________________________________________________Signature: _____________________________________________ Date of Request: ________________________INFORMATION ABOUT REQUIRED CERTIFICATE(S)Landlord or Lessor Municipality OtherLease/Contract No.: ___________________________________________________________________________Name of Event: _______________________________________________________________________________Date(s) of Event: ______________________________________________________________________________Location of Event (List street address if applicable): _________________________________________________________________________________________________________________________________________________Type of Event (Run, Bike, Meal, Meeting,etc.): _________________________________________________________Describe your Participation in Event: ______________________________________________________________Projected number of participants: _____________ Number of volunteers working on event: __________________Will alcohol be available? Yes No If yes, who will serve: _____________________________________Please be advised: Events that involve certain types of risk (eg., athletic events, golf tournaments, events includingchildren, alcoholic beverages, number of participants, etc.) may be charged an additional premium or may requiresupplemental coverage.Other: ________________________________________________________________________________________________________________________________________________________________________________Rev 1/13 1

INFORMATION ABOUT CERTIFICATEHOLDERFull name and address of organization or entity requiring certificate(s) from your organization.(Certificate will be sent to you.)Name: ______________________________________________________________________________________Address: ____________________________________________________________________________________City: ________________________________________________ State: _______________ Zip ______________What is this organization’s involvement? ________________________________________________________________________________________________________________________________________________________Is this organization requesting to be named as an Additional Insured? Yes NoIf yes, provide the exact language required by certificate holder (if unsure, you may attach contract):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________A fee may be charged if a certificate needs to be reissued.CONTACT TO FAX OR EMAIL CERTIFICATE(S)Name: ______________________________________________________________________________________Fax: _____________________________ or Email: ___________________________________________________Name: ______________________________________________________________________________________Fax: _____________________________ or Email: ___________________________________________________Name: ______________________________________________________________________________________Fax: _____________________________ or Email: ___________________________________________________Email request to:AAPAConstituents@novickgroup.comPlease allow at least 48 hours to process request.Rev 1/13 2