CERTIFICATE OF INSURANCE REQUEST - CUNA Mutual Group

CERTIFICATE OF INSURANCEREQUESTDateGENERAL INFORMATIONCredit Union NameContract NumberContact PersonEmail AddressPhone NumberFax NumberMailing AddressStreet City State ZIP CodeName of Organization Requesting the CertificateCERTIFICATE HOLDERAttention To/Contact PersonEmail AddressPhone NumberFax NumberMailing AddressStreet City State ZIP CodeCERTIFICATE HOLDER INSURANCE REQUIREMENTS(If you have a copy of the insurance requirement details, you can attach or fax it with this form)Coverage TypesLimits Minimum Deductibles Waiver of Subrogation? ....... Yes NoAdditional Insured NameAdditional Insured AddressStreet City State ZIP CodeLoss Payee NameLoss Payee AddressStreet City State ZIP CodeType of PropertyLocation of PropertyStreet City State ZIP CodeProof of Insurance Requested for: (select one)A) Events – complete section A belowB) Leased Auto – complete section B belowC) Leased Equipment – complete section C belowD) Leased Premises – complete section D belowReal Estate LendingOther:TYPE OF REQUESTCUP-0809-9200 (R1/13)CUNA Mutual Group, Proprietary and Confidential.© CUNA Mutual Group 2013 All Rights Reserved Do not reproduce without permission from CUNA Mutual Group.

A. For Events Only (Complete this section if you checked the Events box on page 1)Event TitleCredit Union Involvement in the EventEvent LocationStreet City State ZIP CodeEvent DateStart TimeAMPMEnd TimeAMPMB. For Leased Auto Only (Complete this section if you checked the Leased Auto box on page 1)Yes, vehicle is already scheduled on the policy.Year Make ModelNo, vehicle is not scheduled on the policy.Year Make ModelVehicle ID Number (VIN)Original Cost New (if available)Estimated Annual Mileage$Place of GaragingStreet City State ZIP CodeRequested Coverage TypeLimits/Deductible$C. For Leased Equipment Only (Complete this section if you checked the Leased Equipment box on page 1. Formultiple items, attach a list of all leased property/equipment.)Description of EquipmentMake Model Serial Number (if available)Account/Lease/Contract NumberLeasing Company PhoneLocation of Property/EquipmentStreet City State ZIP CodeLoss Payable NameLoss Payable AddressStreet City State ZIP CodeD. For Leased Premises Only (Complete this section if you checked the Leased Premises box on page 1)Credit Union LocationStreet City State ZIP CodeATM LocationStreet City State ZIP CodeCOMMENTSReturn completed form via fax # 608.236.6010 or email to cuprotection@cunamutual.comFor questions contact the Credit Union Protection Response Center at 800.637.2676CUP-0809-9200 (R1/13) - 2 - CUNA Mutual Group, Proprietary and Confidential.© CUNA Mutual Group 2013 All Rights Reserved Do no reproduce without permission from CUNA Mutual Group.