REQUEST FOR EVIDENCE OF COVERAGE

Any contract or agreement requiring an Evidence of Coverage (or Certificate of Insurance) must be reviewed by Enduris prior to issuing the EOC. Documents can be uploaded at the bottom of this form.

Member Name:

Member Contact Name:

Member Contact Email:

Member Phone:

Member Street Address:

Member City State Zip:

Holder (Person/Entity requesting EOC):

Address (Holder):

City State Zip (Holder):

Purpose/Event (please be specific):

Effective Start Date:

Effective Expiration Date:

If Holder is requesting a cancellation clause, how many days are required?

Is Holder requesting to be additional insured?

Yes No

Is Holder requesting to be loss payee?

Yes No

Contract/Agreement Required

Additional Notes:

REQUEST FOR EVIDENCE OF COVERAGE

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