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*
Supervisor/Other Email
example@example.com
Type of Certificate Needed:*

General Liability - ex. event venues, equipment rental, property lease, credentialingAuto LiabilityBoth
One time request or annually renewed certificate?*

One Time RequestAnnually Renewed
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:*

Property Lease
Does the contract require the state to provide the property coverage in addition to the liability coverage?*

NoYes
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
Date
Lease End Date*

MonthDayYear
Date
Address of Property Being Leased*

Street Address

Street Address Line 2

CityState

Zip Code
Property Rental Contract*

Copy of the rental contract.
Cancelof

Comments and Uploads
Comments
Miscellaneous Supporting Documents

Copy of contracts, detailed insurance requirements, etc.
Cancelof
Should be Empty:

Certificate of Insurance Request