Certificate of Insurance Request
Which type of certificate of insurance do you need?
*
Certificate Holder (evidence-only)
Additional Insured
Other
Policy Holder's Name on Policy
*
Doing Business As (DBA)
*
Your Name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your E-mail Address
*
Confirmation Email
example@example.com
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Certificate Holder (evidence-only)
Is this certificate of insurance required for your work as a contractor/subcontractor?
*
Yes
No
Do you have a document to upload with the Certificate Holder's Name and Address as they wish it to appear on the Certificate?
*
Yes
No
Attach and Upload Document(s)
Browse Files
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Choose a file
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Full Name of Certificate Holder
*
Certificate Holder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Certificate Holder E-mail Address
example@example.com
Certificate Holder Fax
Please enter a valid phone number.
Format: (000) 000-0000.
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Additional Insured
How many Additional Insureds need to be added per the signed contract?
*
Please Select
1
2
3 or more
Additional Insured 1
Full Name of Additional Insured
*
Additional Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Insured E-mail Address
example@example.com
Additional Insured Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Insured 2
Full Name of Additional Insured
*
Additional Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Insured E-mail Address
example@example.com
Additional Insured Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Insured 3
Full Name of Additional Insured
*
Additional Insured Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Insured E-mail Address
example@example.com
Additional Insured Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Insured Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have more Additional Insureds that need to be added to the policy?
Yes
No
Please upload all documents pertaining to the project, including signed contract
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Additional Insured special wording
*
Is there a written contractual obligation to name the above an additional insured (s)?
*
Yes
No
Will you be working at a single location, or multiple locations?
*
One location
More than one location
Address of the work to be completed:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Describe Work Locations:
*
Date work is scheduled to begin
*
-
Month
-
Day
Year
Date
Date work is scheduled to be completed
*
-
Month
-
Day
Year
Date
Additional Insured Requests (Check ALL that apply):
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Primary/Non Contributory Status
Waiver of Subrogation
Per Project Aggregate
Per Location Aggregate
Wording to reference a specific property, project, vehicle, etc
Additional Wording/Special Requests
Completed Operations
None
Unknown
Job is
*
Residential
Commercial
Industrial
Residential Only
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Remodel
New Construction
Service and Repair
Room Addition
If the job is NEW residential construction, is it condominiums, TRACT HOUSING, subdivisions, townhouse, tract housing or apartment buildings ?
*
Yes
No
Development Name
*
What is the total number of housing units in the development?
*
What is the total number of housing units YOUR COMPANY will work in across all phases of the development?
What is the total number of housing units YOUR COMPANY will work in across all phases of the development?
*
Include all phases of the development, including completed, under construction and planned.
Detailed Job Description; describe the work the YOUR COMPANY will perform for the Additional Insured
*
Does the ADDITIONAL INSURED maintain their own liability insurance to cover their own exposures? If not, certificate will NOT be processed.
*
Yes
No
Additional Wording/Special Requests (do you need special endorsements and/or wording)?
*
Additional Policies Required by the Additional Insured (Check ALL that apply):
*
Commercial Auto - Evidence Only
Commercial Auto - Additional Insured
Excess Liability/Umbrella
Pollution
Professional Liability
Workers Comp / WA Stop Gap
None
Unknown
Do you have any additional supporting documents or sample certificates to upload with this request?
*
Yes
No
Attach and Upload Documents
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Additional Information
Is there anything else you would like us to know regarding this request?
Submit
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