Certificate of Insurance Request
If any questions, please contact our office at (845) 778-2141
Policy Holder's Name and DBA
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Name of Insured (YOUR business)
Your Policy Number
Your E-mail Address
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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)
*
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)?
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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
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What is the requested Additional Insured's relationship to you? (General Contractor, Investor, Property Manager etc.)
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Does the additional insured maintain their own insurance to cover their own exposures? If not, certificate will NOT be processed.
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Yes
No
Job/Project Location
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For “Various Locations” – provide 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
COMMENTS (do you need special endorsements and/or wording; do you need to list your commercial auto, workers’ comp or other policies?)
Attach and upload documents if necessary
Upload a File
Copy of contracts, detailed insurance requirements, etc.
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Thank you for the opportunity to assist you!
By clicking Submit, I 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 and/or fee. Correctly completed certificate requests will be processed within 24 hours.
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