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Performer Certificate
Insured's First Name
*
Please use proper name capitalization.
Middle Initial
Insured's Last Name
*
Business or Performer Name
Insured's Email
*
Please type only one email.
Certificate Holder
Venue where you are performing
Additional Insured Name: (Venue that is asking for certificate)
*
Attention (contact person)
Address
*
City
*
State
*
Please Enter State Abbreviation Ex: Florida = FL
Zip Code
*
Additional Insured: (special language may be required - read your contract)
Attach A File
Attach a File (Insurance Guidelines, Sample Certificates, Venue Information)
Files must be less than
6 MB
.
Allowed file types:
txt doc docx xls xlsx pdf jpg jpeg gif png
.
Email For Event
Fax Number For Event
Format: xxx-xxx-xxxx
Event Date(s)
*
Date Needed - Click in box for popup calendar
*
Date
E.g., 2019-06-24
Additional Email
Process ASAP
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