Certificate Request

Named Insured:

This is the name of our client who you are requesting the Certificate from: the Named Insured on the policy shown on the Certificate. This is the name that will appear in the "Insured" box on the Certificate.

Certificate Holder Name:

Please state the name of the Certificate Holder as you wish it to appear on the Certificate. The Certificate Holder is the person or entity requesting the Certificate from the Named Insured.

Certificate Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select all policies that you would like to appear on the Certificate:

If other, please state the line of coverage requested:

What aggregate would you like on the general liability coverage?

If specific auto liability symbols are requested, please indicate those here:

Are any Interested Parties requested? Interested Parties are those receiving any kind of coverage under the policy, such as additional insured or waiver of subrogation, for example.

Are the name(s) and address of the Interested Parties the same as what you entered previously for the Certificate Holder?

Please state the name of any Interested Parties requested:

Address of Interested Parties

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the relationship of the Interested Parties to the Named Insured (our client)? This helps us to determine which coverge endorsements are most appropriate.

If Other, please describe the relationship:

Please select all general liability coverages requested by the Interested Parties:

If Other, please state the additional coverage(s) requested:

Please select all auto liability coverages requested by the Interested Parties:

If Other, please state the additional coverage(s) requested:

Please select all umbrella / excess liability coverages requested by the Interested Parties:

If Other, please state the additional coverage(s) requested:

Please select all worker's comp / stop gap liability coverages requested by the Interested Parties:

If Other, please state the additional coverage(s) requested:

Did the Named Insured (our client) sign a written contracting requiring all coverages selected above for the Interested Parties?

NOTE: if there are Interested Parties requesting coverage on the policy, but there is not a written contract that requires the coverage, we will have to request for the coverage to be scheduled on the policy. Some carriers may refuse to schedule coverage when there is not a written contract in place, so we will notify you if what you have requested is not possible without a written contract.

Scheduling coverage usually costs additional premium. We cannot issue the Certificate until we have the endorsements from the carrier, so it may take additional time for you to receive your Certificate as well. Carrier processing times vary from 2 days to 2 weeks.

If so, was each of the Interested Parties also a party to the written contract with the Named Insured (our client)?

NOTE: if there are Interested Parties requesting coverage on the policy, but they are not parties to the written contract that requires the coverage, we may have to request for the coverage to be scheduled on the policy. Even if your policy has a "blanket" endorsement, coverage on that endorsement may be limited to parties to the written contract with the Named Insured. The language on the "blanket" endorsements varies by carrier and by policy, so we will review the endorsements that the Named Insured has and let you know if scheduled endorsements are needed.

Scheduling coverage usually costs additional premium. We cannot issue the Certificate until we have the endorsements from the carrier, so it may take additional time for you to receive your Certificate as well. Carrier processing times vary from 2 days to 2 weeks.

Please state any other details that you wish to add to your Certificate Request:

You may upload any documents relevant to your request, here. Relevant documents may include sample Certficiates, insurance requirements, contracts, and so forth.

IMPORTANT NOTES:

All Certificates will be issued in compliance with WAC 284-30-355 and do not alter, amend, or extend the coverage provided by any insurance policy.

While we do our best to provide evidence of the coverage requested in any contract(s) provided to us, we cannot guarantee compliance with your contract(s). We do not practice law. Questions regarding compliance with any of your contracts should be directed to your attorney.

All information provided to us on this form or in written or oral communication regarding this Certificate Request is material and will be relied upon in creating this Certificate. Errors in that information must be reported to us immediately.

In the event of any conflict between the information you have provided on this form and any uploaded documents, the information that you have provided on this form will govern. We may ask you for clarification and may adjust the Certificate based on your responses; however, we are not liable for any errors in the Certificate based upon our reliance upon the information that you have provided on this form or as part of those communications.

Your Email Address (in case we have questions regarding this request):

example@example.com

Email Address for Certificate Delivery:

example@example.com

Date by which you would like the Certificate delivered:

Date

Please sign here to certify that the information provided herein is true, correct, and complete to the best of your knowledge:

Name of Person Completing This Form:

First NameLast Name

Title / Company, if applicable:

Certificate Request Form

Basic Information

Interested Parties

Certificate Completion

IMPORTANT NOTES:

Please sign here to certify that the information provided herein is true, correct, and complete to the best of your knowledge: