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Request for Certificate of Insurance

For our Existing Customers ONLY!
Complete the following form to request a certificate of insurance, or to include an Additional Insured person on your policy.

*Required Information

Insured's Name:*
Name of Person
Requesting Certificate:*
Certificate Holder Information:
Company or Person requesting Certificate of Insurance from you.
Company or Person Name: *
Attention To:
Address: *
City, State, Zip:*

City
State
Zip (5 or 5-4)
Project Name/Job/Description and
Location of Operations: *
Type of Insurance:*
Check all that apply.
General Liability
Automobile Liability
Umbrella/Excess Liability
Workers Compensation
Property
Other: (Please Specify Type)
Certificate Forwarding Instructions:*
Name:
Send Emails to: 1. 
2. 
3. 
Fax to: 123-456-7890
Mail to:  
     Address:
     City, State, Zip:

City
State
Zip (5 or 5-4)
Include an Additional Insured for General or Automobile Liability.
ADDITIONAL INSURED QUESTIONNAIRE
 If you are requesting an Additional Insured for General Liability or Automobile Liability,
you must also complete the following information.
A copy of the written contract may be requested for additional information.
Additional Insured is:*

Name(s) of entity requesting to be added as Additional Insured: *
Name(s): *
For multiple names
please enter 1 per line.
Text boxes will expand as necessary.
Type of work to be done
for the Additional Insured: *

Is there any written contract
between the Named Insured
and the Additional Insured?*

 No    Yes
If yes, policy must provide or be endorsed to provide
Contractual and Products/Completed Operations.
Contract cost of work
to be done for the
Additional Insured: 		$
Does the Additional Insured
maintain primary insurance
to cover the exposures
at risk? 		No    Yes    Unknown
If no, submit this request
to your Company underwriter for approval.
Submission Date: September 5, 2010
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