Certification Request

You must fill in all fields, otherwise the form will not be processed. Do not forget to include your email address at the bottom.
   
Name of Insured
First Name of Contact Person
Last Name of Contact Person
How do you prefer to be contacted
if we need to clarify some information?		 Fax
Phone Number (of Contact Person)
Fax Number (of Contact Person)
E-mail Address
Do you require a mailed copy?
Certificate Holder's Name
Certificate Holder's Address
Certificate Holder's City
Certificate Holder's State
Certificate Holder's Zip
Certificate Holder's Email Address
Attention
Identify Certificate Holder Type
  Evidence of insurance only
  Loss Payee: The Certificate Holder has an insurable/financial interest in the property.
     The Property IS NOT a building (e.g. a bank financing a vehicle)
  Mortgages: The Certificate Holder has an insurable/financial interest in the property.
     The Property IS a building. (e.g. a bank financing a building)
  Additional Insured: The Certificate Holder has requested to be named as an additional insured on the policy for liability purposes. (Adding an additional insured to your policy may change your premium.)
Is there any special wording required on your certificate by the certificate holder?
Number of Days required for Cancellation Clause
What coverages do you need to have verified on this Certificate of Insurance? General Liability
Automotive Liability
Garage Liability
Automobile Physical Damage
Property Insurance
Workers Compensaion
Umbrella Liabiility
Inland Marine
Other

What are the effective dates of insurance coverage that you need the certificate for? (Month & Year BEGINNING)
What are the effective dates of insurance coverage that you need the certificate for?(Month & Year ENDING)