Certificate of Insurance Request
If any questions, please contact our Certificate Department at (800) 750-2663
Policy Holder's Name and DBA
*
Name of Insured
Your E-mail Address
*
Phone Number
*
-
Area Code
Phone Number
Requested by
*
First and Last Names
Your Policy Number
Name and Address of Certificate Holder
*
Email or Fax of Certificate Holder
Name certificate holder as Additional Insured
*
Yes
No
Additional Insured Name(s)
Please list names of Additional Insured(s); separate additional names with a comma or semi-colon.
Is there a contractual obligation to name the above additionally insured (If no, explain why needed)?
*
Please Select
Yes
No
If no, explain why needed?
Project is occupied by or will be occupied by (Example: store, dwelling, hospital)
*
Detailed Job Description; describe the work the named insured will perform for the additional insured
What are the operations of the requested additional insured?
*
Is the additional insured involved with NEW construction of condominiums, tract housing, subdivisions, townhouses or apartment buildings:
*
Yes
No
Does the additional insured maintain their own insurance to cover their own exposures? If not, certificate will NOT be processed.
*
Yes
No
Job/Project Location
*
For “Various Locations” – privide city(s) or county(s)
Project is occupied by or will be occupied by (Example: store, dwelling, hospital)
*
The job is:
*
Please Select
Industrial
Residential
Commercial
For residential Jobs
*
Please Select
Remodeling
New Construction
Repair and Service
Room Additions
If the job is NEW residential construction, is it condominiums, tract housing, subdivisions, townhouse, tract housing or apartment buildings ?
*
Yes
No
Is the job work for a construction defect claim?
*
Yes
No
Comments
File Upload
Upload a File
Copy of contracts, detailed insurance requirements, etc.
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By clicking Submit, I understand that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY. Endorsements and/or Special Wording may require additional processing time and/or fee. Correctly completed certificate requests will be processed within two business days.
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