Certificate of Liability Coverage Request Form Use this form to request a Certificate of Liability Coverage Certificate of Liability Coverage (COLC) Request Form Contact InformationMunicipality requesting COLC:*Brigham CityCedar CityCentervilleDraperEnterpriseFarmingtonKanabLaytonMapletonOgdenOremSouth JordanSpanish ForkWest BountifulWest ValleyContact Name:* First Last Contact Email address:* Contact Phone Number:*The best number to contact you if we have questions.Certificate InformationName of Entity Requesting Certificate:*Those wishing to be listed as Loss Payee/Additional Insured on the Certificate (i.e. UDOT, Zions Bank etc.)Address of Entity Requesting Certificate:*Address of the Loss Payee/Additional Insured on the Certificate Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Purpose of coverage:*Please include name of event, description of activity.Dates of requested coverage:*Please include dates that coverage is requested.Additional Information/Instructions:Please enter any additional information/instructions hereFile Upload:Please upload any documents associated with the request for Certificate of Liability Coverage here: Drop files here or Additional Persons Requesting Copy of CertificateInclude anyone that would like a copy of the Certificate emailed to them. Name: First Last Email: Name: First Last Email: Name: First Last Email: CAPTCHAUntitledUntitled
