Order Certificate

CERTIFICATE REQUEST FORM

Certificate Holder:

Address:

City:

State:

Zip:

Risk Management Consultant:

Telephone #:

Facsimile #:

E-mail:

Name of Municipality:

Address:

City:

State:

Zip:

COVERAGES AND LIMITS REQUESTED:

RENEW ANNUALLY? Yes No

	COVERAGES:	LIMITS:
	General Liability
	Auto Liability
	Auto Physical Damage
	Excess Liability
	Property
	Workers Compensation
	Public Officials Liability
	Crime/Fidelity Bond

DESCRIPTION:(include purpose of certificate, additional insureds, loss payees, etc.)

*If this is a new vehicle, has the Fund Administrator been notified to add this vehicle to the member's schedule.

Yes No

Revised 07/14/05

©Burlington County Municipal Joint Insurance Fund. All rights reserved.

Burlington County Municipal Joint Insurance Fund

www.burlcojif.org

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