CERTIFICATE OF INSURANCE REQUEST FORM

Local Government Insurance Trust
7225 Parkway Drive									Phone Number: 443-561-1700
Hanover, MD  21076									Fax Number:     443-561-1701
Attention:	Scott Soderstrom or 	Ellen Nudd

Member Requesting Certificate of Insurance:      	

SELECT COVERAGES REQUIRED	
General Liability	     	Property	     	
Business Auto Liability	     	Boiler & Machinery	     	
Excess Liability	     	Crime	     	
Other	     	Other	     	

CERTIFICATE HOLDER INFORMATION	
Certificate Holder Name:      
	
Attention:      
	
Address:      

Phone #:      
	
Fax or E-Mail Address:      

Special Wording Required:          Additional Insured                      Loss Payee                              Mortgagee	

The purpose/language on the Certificate of Insurance should include the following where applicable:  
Location, Serial & Model Number, Replacement Cost Value (RCV), Actual Cash Value (ACV), Stated Value, Loan or Lease Number, Effective Date or Date of Event.
     						

Mailing Specifications:	     		Original and one copy to me (please write name/address below) 
	     		Original to Certificate Holder, copy to me 
	     		Fax copy to me immediately at:      	
	Then mail as indicated above
Request Submitted by:      		Date:      	

Address:      		Phone:      	

     		FAX: