YOUR DEPT/AGENCY	     	
YOUR NAME	     	
YOUR PHONE/FAX	     	

What company/organization is requesting the certificate of insurance from you?
CERTIFICATE HOLDER INFORMATION (Who is requesting the insurance from you)	
COMPANY NAME	     	
ATTENTION:	     	
STREET ADDRESS	     	
TOWN	     	
STATE	     	
ZIP	     	

Is this certificate request relating to an equipment lease? 		 Yes	 No
If no, skip to the next section.          If yes, provide the following information:
LEASE NUMBER	     	
LEASE EFFECTIVE DATE	     	
LEASE TERMINATION DATE	     	
TYPE OF EQUIPMENT	  Computer	      Copier	    Postage Meter		
		Other – Describe:	     	
BRAND NAME	      	
MODEL NUMBER(S)	     	
SERIAL NUMBER(S)	     	
REPLACEMENT VALUE	     	
OTHER RELEVANT INFO	     	
Is this company/organization requiring loss payee status? 		 Yes	 No
Is this company/organization requiring additional insured status? 	 Yes	 No
Note: Naming an additional insured on your insurance policy is not desirable and should only be done when absolutely necessary!

Is this certificate request relating to the use of another’s premise to hold an event?     Yes	 No        
If no, skip to the next section.          If yes, provide the following information:
DATE(S) OF EVENT	     	
EVENT DESCRIPTION/TITLE	   	
 Is this company/organization requiring additional insured status? 	 Yes	 No
Note: Naming an additional insured on your insurance policy is not desirable and should only be done when absolutely necessary!

If certificate is neither for an equipment lease nor a use of premise, please call Risk Management with details (287-3351 or 1-800-525-1252).
It is our practice to email the certificate to you and have you distribute it as needed.  Is this how you want this certificate handled?	 Yes    No  		If no, how do you want it handled?
	Mail a copy to the Certificate Holder		Fax a copy to Certificate Holder	
	Other – describe:	     	
Complete and e-mail to Risk Management Division (jen.maddox@maine.gov, sheena.greenlaw@maine.gov)  OR Fax to 287-4008.