SOLICITAÇÃO DE CERTIFICADO DE SEGURO

(Antes de preencher este formulário, leia o documento Solicitação de Certificado de Seguro [TO-17i] com atenção. Se
possível, preencha este formulário eletronicamente.)

SOLICITANTE (entidade jurídica que solicita o certificado)

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(Nome completo da entidade) (Número da congregação, se for o caso)

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(Endereço de correspondência)

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(Cidade) (Província ou estado) (Zona ou código) (Pa ís)

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(Nome do irmão que serve como contato principal) (Telefone residencial/celular) (Data da solicitação)

EVENTO
˚ Celebraãoo ˚ Assembleia/Congresso ˚ Outro: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Especifique)

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(Data de entrada e sa ída ou data[s] de uso)

ADMINISTRADOR OU PROPRIETÁRIO DO LOCAL

(empresa ou pessoa que solicita comprovante do certificado de seguro)
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(Nome)

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(Endereço de correspondência)

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(Cidade) (Província ou estado) (Zona ou código) (Pa ís)

INFORMAÇÕES SOBRE O LOCAL (no caso de prédio ou terreno alugado)

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(Nome oficial)

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(Endereço)

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(Cidade) (Província ou estado) (Zona ou código) (Pa ís)

INFORMAÇÕES ADICIONAIS

Limite necessário: __________________________________________________________________________________________________________________________________________________________ Moeda: __________________________________________________________________________________________________________________________________________________________ Seguro adicional: ˚ Sim ˚ Não

Fraseologia específica solicitada:

Envie o formulário preenchido para o Departamento Financeiro. Inclua o “TO-17” na linha “assunto” da
mensagem.

TO-17-T 10/23