Contractors' Certificate Request

REMINDER: To expedite your request and to eliminate potential underwriting declinations, please forward a copy of the insurance requirements found in your contract. With the ever-changing legal environment and insurance carrier regulations, lack of information can and will delay our normal service and quick turn-around time.

Date:
Insured Name:
Contact:
Insured Phone:
Insured FAX:
Certificate Holder:
Contact:
Address:
City:
State:
Zip:
For (job reference):
Phone of certholder:
Fax:
Email (vs. fax):
Please fill out the section below if other changes are requested by the certificate holder (per the reminder above, substantial changes could cause some delay as underwriting acceptance will be required).
1) Cancellation Notice:	10 days 30 days
2) Certificate holder also named as:	Additional Insured Primary Named Additional Insured (list all parties, if any, as there may be more than one):
3) Primary and non-contributory wording?	Yes No
4) Waiver of Subrogation required?	Yes No
5) Remove the wording “Endeavor to” and “Failure to do so shall impose no obligation?	Yes No
6) Any specific “CG” forms requested?	Yes No If yes, which one?:
7) For any Additional Insured and/or Waiver of Subrogation request, the following items are required:
Name of Job:
Project # (if any):
Does this project involve tract homes or multi family dwellings:	Yes No
Description of job:
Total Cost of job:
Total payroll for job:
Completion Date:

If questions persist, please call your agent or account manager

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