Insurance Request EOBA | Register OBA

2024 Insurance Certificate Request Form -EOBA

All information must be provided to expedite your request. Missing information will result in a delay. Please allow 2 business days to complete your request.

Local Association Contact Information

First Name

Last Name

Phone

Local Associatin

Affiliate DESIGNATE - Contact Info

Insurance Information

If yes - Additional insured name and address is a MUST!. Please note, proper legal name and full address are required. Missing information will result in your request being denied.

Please select

YES

Additional insured name and address. Please note, proper legal name and full address are required. Missing information will result in a delay.

Additional Info

I confirm I have entered the full insured name and address in the above text box. I further understand that my request will be denied if incomplete.