Request for Certificate of Insurance for Codemoji, Inc

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IP_Cert_No
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Date
Your first and last name*
First Last
Your email address*
We will send the certificate of insurance to the email address entered in this field
Name of the Certificate Holder*
it will appear on the certificate exactly as you put it (i.e. ABC School District)
Continue Name of the Certificate Holder
Certificate Holder Address 1*
Certificate Holder Address 2
City*
State*
Zip Code*
Additional Notes
Please include any additional instructions. This information will not be included on a certificate of insurance. It will only be sent to Paperless Insurance Services, Inc.
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Name Insured
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Name Insured address 1
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Name Insured city/state/zip
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Insurer A
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Insurer A NAIC
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INSRD LTR A
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ADDNL INSRD CHECKED
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GL POLICY #
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GL EFF DATE
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GL EXP DATE
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GL Each Occ
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GL Pers Adv Inj
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GL Fire Dam
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GL Med Exp
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GL GEN AGG
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GL PROD COMP OPS
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OTHER TYPE OF INSURANCE 2 Molestation or Abuse
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OTHER TYPE OF INSURANCE 1 PROF LIAB
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OTHER Limit Desc 1
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OTHER Limit Desc 2
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OTHER Limit 1
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OTHER Limit 2
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Description of Operations
With regard to general liability, when required by a written agreement, the certificate holder is additional insured per form L-723 attached to the policy. With regard to general liability, when required by a written agreement, this insurance is primary and non-contributory, per form L-723 attached to the policy.
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Checkbox
- X