YOUR DEPT/AGENCY	     	
YOUR NAME	     	
YOUR PHONE/FAX	     	

CERTIFICATE HOLDER INFORMATION (Who is requesting the insurance from you)	
COMPANY NAME	     	
ATTENTION:	     	
STREET ADDRESS	     	
TOWN	     	
STATE	     	
ZIP	     	

PROPERTY REQUESTS: (LEASED/RENTED SPACE or EVENT LOCATIONS)	
DATES:	     	
ADDRESS:	     	
LEASE #	     

	
EVENT DESCRIPTION:    	     

  EQUIPMENT 
BRAND NAME	      	
MODEL  	     	
VIN OR SERIAL #	     	
COST NEW 	     	
RENTAL/LEASE DATE(S)	     	
EQUIPMENT USE:		     	

You must provide a copy of the lease/rental agreement and the insurance requirements with your COI request.

Questions, contact Risk Management (287-3351 or 1-800-525-1252).
Complete and e-mail to Risk Management Division (jen.maddox@maine.gov)  OR Fax to 287-4008.