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2. Contractor/Vendor Name:
3. Contract Number:
5. Insurance Carried:

   1. Workers' Compensation
   2. Commercial General Liability
   3. Automobile Liability
   4. Excess/Umbrella Liability
   5. Professional Liability
7. Workers' Compensation Waiver of Subrogation:
   -- Select One --YesNo
8. Additional Insured Endorsement:
   -- Select One --YesNo
10. Limit of General Liability Insurance:
11. Limit of Automobile Liability Insurance:
13. Limit of Excess/Umbrella Liability Insurance:
14. Limit of Professional Liability Insurance:
16. Certificate of Insurance:

    1. Approved Insurers
    2. Adequate Policy Expiration Date
    3. Description Accurate
17. Expiration Date of COI:
    Expiration Date of COI:
19. Comments/Exceptions/Recommendations:
21. Documents Needed for Approval:
23. Risk Management Determination:
    -- Select One --ApprovedDeclinedPending
24. Returned to:
    -- Select One --Jessica LewisJonathan PiersonPatricia RyanRegina WashingtonThomas EllisonBridget BakerChristos Bazekis
25. Today's Date:
    Today's Date:
26. Reviewed by:
    -- Select One --Marcus OdorizziJamie Kohler
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

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30. Submit

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