Certificate Request
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Company Information
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Company Name
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Address
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Phone Number
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Fax Number
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Email
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Certificate Holder - (Provide Name, Address, & all pertinent information)
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Name
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Address
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Attention Of
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Phone Number
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Fax Number
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Coverage Information - (We will evidence all coverages unless you specify otherwise)
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General
Liability
Automobile
Umbrella
Workers'
Compensation
Property
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Comments/Remarks
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Certificate Holder's Interest - (Important if named as Additional Insured)
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Owner
Mortgagee
Lessor
Franchisor
General
Contractor
Political
Entity
Other
Interest
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If Other Interest
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Describe Operations, Equipment, Vehicles, Other - (Provide job locations, property locations, loan numbers, etc.)
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Additional Insured: (Exact name to be added to your policy)
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Effective Date:
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Cancellation Clause if Other than 30 Days
Except 10 Days for Non-Payment of Premium (Requires company approval)
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Days Requested:
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Other Special Terms and Conditions - (List any important exclusions or endorsements required)
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Completed Certificate - (Indicate distribution of the Certificate)
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Mail/Fax Copy to Certificate Holder
RUSH Issue
(within 2 hours)
Mail/Fax
Copy to our office
Standard Issue
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E-Mail to:
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