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Certificate of Insurance

Insured Name:*	Address:

City:	State

Zip:	Requested by:

Position at Church:	Email:*

Phone:	Fax:

Certificate Holder / Additional Insured
Name:	Address:

City:	State:

Zip	Attention

Phone#:	Fax

Certificate Holder To Be Named
Additional Insured	Loss Payee

Evidence Of Property Damage	Landlord

Mortgagee	On going?

Reason for Certificate (Description of activity, or property address)	Dates, Amounts of people, Equipment

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What Our Clients Say

I met Judith Blackwell in 1994, Blackwell Church insurance was highly recommended by a couple of work colleagues.
Gary Prem

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Phone: (800) 255-1460
Fax: (949) 421-0223
Email: info@blackwellins.com
Street: 23201 Lake Center Dr #310, Lake Forest, CA 92630

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