Ministry Pacific, LLC - Certificate Request

Church/Organiztion Name:
Policy Number:	A value is required.Invalid format. A value is required.Invalid format.
Your Name:
Your Phone Number:	A value is required.Invalid format.
Your FAX Number:
Your Email:

Dates of the event:	A value is required.
Will this event be ongoing?:	Yes No
Would you like a copy of the Cert.?:	Yes No
Briefly Describe the event or reason for the certificate.
Type of Event:
Description of Activities (required):
Estimated Number of People Attending?:	Invalid format.
If this is an ongoing event and you will be in a building, what is the approx. sq. feet that you will be using?
	Invalid format.
Is this an overnight event with minors?	Yes No
If yes, have you completed background checks for all counselors that will be overnight with the minors?
	Yes No
Please provide complete information on the entity requesting the certificate (this is NOT your organization):
Legal Name:
Mailing Address:
City:	State:
Zip:
Contact Name:
Contact Phone:	A value is required.Invalid format.
Contact Fax:	A value is required.Invalid format.
Contact Email:	A value is required.Invalid format.
What is the address where the activity will be held if different than above:
Physical Address:
City:	State:
Zipcode:
Notes/Comments:
This request is for Verification of Coverage Only.	Yes No
Are they requesting to be listed as an Additional Insured?	Yes No
(If your answer is Yes to the above question, there may be a charge to your policy. If you have any questions about this or anything else, please contact us by phone or email)