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Professional-Liability

Request A Certificate of Insurance

Insured

* Required
MM slash DD slash YYYY
MM slash DD slash YYYY

Holder Information (organization/person requesting Certificate from Insured)

Other Certificate Information

If the Holder/requestor has provided written Certificate requirements, please send the requirements by fax to 301‐417-0040 or email us at customerservice@moodyinsurance.com
If the Holder/requestor has provided written Certificate requirements, please send the requirements by fax to 301‐417-0040 or email us at customerservice@moodyinsurance.com
Holder requires status as either/both
If Additional Insured and/or Loss Payee is required, what is your relationship to the Holder?
For any of the above, is there a written contract in place?
If there is a written contract, please send a copy of the insurance provisions section by fax to 301‐417‐0040 or email us at customerservice@moodyinsurance.com.

Distribution Instructions

To Holder
To Insured