Mercer Consumer, a service of
Mercer Health & Benefits Administration LLC
PO Box 14575
Des Moines, IA 50306
Certificate of Insurance Request Form
Clubs Only:
Are you a current, active member of your organization?
Name of Organization or Association?
Club Name?
Yes No
1. Policy or client number:
2. Name, title and address of insured:
3a. Phone: 3b. Email:
4. How would you like the certificate of insurance delivered to you?
a. Email
b. Mail
Event Information:
5. Name of event:
6. Location of Event (name & address):
7. Date of the event(s):
8a. Name & address of entity requesting proof of coverage:
8b. Is the entity requesting to be named as an additional insured? Yes No
8c. Does the entity own the event location? Yes No
8d. Explain the additional insured's role/interest in the event:
9. Type of event(meeting, musical performance, etc):
10. Explain your role/activities with respects to this event.
Signature:
Date:
Please fax or email your request to:
Fax: 515-365-3005
Email: plsdsteam.service@mercer.com
In CA d/b/a Mercer Health & Benefits Insurance Services LLC
AR Insurance Lic
ense #303439 | CA Insurance License #0G39709
Mercer Consumer, a service of
Mercer Health & Benefits Administration LLC
