Certificate of Insurance Request
Severson Insurance Agency
General Information
Name of Insured:
*
First Name
Last Name
Name or Company of Certificate Holder:
Job Reference Number:
Address of Holder:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Holder Phone Number:
Please enter a valid phone number.
Holder Fax Number:
Please enter a valid phone number.
Your Name:
*
First Name
Last Name
Contact Email:
*
example@example.com
Handling Method:
Fax
Email
Required Coverages
Please Provide Copy of Insurance Requirements of Contract
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation?
Yes
No
Need Endorsements for Primary Wording?
Yes
No
Loss Payee
Yes
No
Mortgagee
Yes
No
Additional Insured
Yes
No
Comments or Other Instructions:
Attach File(s):
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Please attach written request(s) and/or contracts received, if any.
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