JCI Michigan Insurance Information Request
By filling out this form, you are requesting coverage information from our state insurance provider.
Chapter
*
Please Select
Allegan
Alpena
Ann Arbor
Auburn
Big Rapids
Cadillac
Central Woodward
Clare Area
Farmington Area
Frankenmuth
Gaylord Area
Grand Rapids
Greater Flint
Greater Muskegon
Ionia
Kalamazoo
Lansing
Livonia
Ludington
Manistee
Mt Pleasant
NoMi
Redford
Rochester Area
Saginaw
South Kent
Westland
Wyandotte
Number of Members
*
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone
*
Please enter a valid phone number.
Contact Fax
Please enter a valid phone number.
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Certificate of Insurance
Requesting Entity Name
*
Requesting Entity Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requesting Entity Phone
*
Please enter a valid phone number.
Type of request
*
Additional Insured
Proof of Insurance
Relationship to Project
*
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Event Information
Project Name
*
Project Chair
*
First Name
Last Name
Project Description
*
Alcohol Related
*
Yes
No
Expected # of Participants
*
Project Location Name
*
Project Location Adress
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Date Start
*
-
Month
-
Day
Year
Date
Project Date End
-
Month
-
Day
Year
Date
Quote request for
*
Special Event Coverage
Liquor Liability Coverage
Liquor Bond Coverage
Individual Club Director's & Officer's Coverage
Club Dishonesty Bond Coverage
Other
Submit
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