Certificate of Insurance Request
If any questions, please contact us at 1-800-242-4337.
Policy Holder's Name and DBA
*
Name of Insured (YOUR business)
Your Policy Number
Your E-mail Address
*
Insured's Phone Number
*
-
Area Code
Phone Number
Requested by (Your First/Last Names)
*
Your First and Last Names
Name and Address of Certificate Holder (Person or entity asking you for insurance) & Job Reference Number
*
Email or Fax of Certificate Holder
Does the Certificate Holder want to be named as Additional Insured?
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Yes
No
Additional Insured Name(s)
Please list names of ALL 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?
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Detailed Job Description; describe the work the named insured will perform for the additional insured
*
What is the requested Additional Insured's relationship to you? (General Contractor, Investor, Property Manager etc.)
*
Is the additional insured involved with NEW construction of condominiums, tract housing, subdivisions, townhouses or apartment buildings:
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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
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For “Various Locations” – privide city(s) or county(s)
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 (do you need special endorsements and/or wording; do you need to list your commercial auto, workers’ comp or other policies?)
DGK thanks you for the opportunity to assist you!
By clicking Submit, you 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. Correctly completed certificate requests will be processed within two business days.
Submit
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