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2024 Insurance Certificate Request Form -ICBA

All information must be provided to expedite your request.  Missing information will result in a delay.  Please allow 2 business days to complete your request.

Local Association Contact Information

Affiliate  DESIGNATE  - Contact Info

Insurance Information

Do you require a Certificate of Insurance with a specific additional insured?

Ex)  Municipality, school board, training facility

Please select

If yes - Additional insured name and address is a MUST!.  Please note, proper legal name and full address are required.  Missing information will result in your request being denied.

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