Certificate of Insurance Request

 

Insured's Company Name & Address:	Company Name Street, Suite City State     Zip
Contact Name
E-mail
Phone Number	() - X Phone
Fax Number	() - Fax
Coverages to be listed on Certificate:	General Liability Auto Liability Workers' Comp Umbrella Liability
Certificate Holder Information:	Company Name Contact Street, Suite City State     Zip () - X Phone () - Fax
Send Certificate by:	Fax   Mail
How do you wish to receive receipt of delivery?	Fax    Mail
Type of Certificate needed:	Select Type of Certificate Holder named as Additional Insured Holder named as Additional Insured & Loss Payee Holder listed as Certificate Holder only
Relationship:	Select Relationship Holder is landlord Holder is lessor of equipment or vehicles Holder is party to a contract for services Other (explain below)
Please give any additional information or instructions:
Thank you!