Idaho State Liability and/or Property Insurance Certificate Request Form

Certificate of Insurance Request
Requesting Agency
State Personnel Initiating Request

First NameLast Name
Your E-mail Address
example@example.com
Phone Number
Format: (000) 000-0000.
Supervisor/Other Email
example@example.com
Which Fiscal Year is this certificate for?
Type of Certificate Needed:
One time request or annually renewed certificate?
Per Idaho Statute 6-924, the limit of liability for the State is $500,000.00. Risk Management does not issue certificates in excess of this amount except in situations with extenuating circumstances. If it is determined that a certificate in excess of the $500,000.00 is necessary, there is a charge of $5000.00 per certificate to the requesting agency. Most entities that the state issues certificates to are understanding of these limitations when explained.

If you would like to discuss these limits further, please reach out to our Risk Analyst at admriskunderwriting@adm.idaho.gov or 208-332-1868.
Certificate Holder Information
Certificate Holder (Non-State Entity Requesting Certificate)
Address of Certificate Holder

Street Address

Street Address Line 2

CityState

Zip Code
ATTN TO: (if required)
Job, Location or Contract /Ref# if required to be noted on certificate:
Choose what type of situation this certificate is for:
- Event/Contract Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Event/Contract End Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Event or Contract Name:
- Purpose of Event and Estimated Number of Participants
- Credentialing Agreement Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Credentialing Agreement End Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Credentialing Agreement Overview
- Does the contract require the state to provide the property coverage in addition to the liability coverage?
- If "yes" above - Confirm that this property has been entered into Origami and provide the building value here:
  Building value as stated in Origami
- Lease Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Lease End Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Address of Property Being Leased
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Property Rental Contract
  
  Copy of the rental contract.
  Cancelof
- Rental Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Rental End Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Model
- VIN/Serial Number
- Dollar Value of Equipment
- Rental Agreement/Contract
  
  Upload a copy of the rental agreement/quote/contract.
  Cancelof
- Auto Lease Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Auto Lease End Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- VIN:
- Vehicle Year, Make, Model
- Dollar Value of Vehicle
- Comments
- Miscellaneous Supporting Documents
  
  Copy of contracts, detailed insurance requirements, etc.
  Cancelof
- Should be Empty:

Certificate of Insurance Request

Certificate Holder Information