Certificate Request

Certificate Request Form

Certificate of Property Insurance - Acord 27
Basic Information
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 coverages that you would like to appear on the Certificate:
Please describe the Scheduled Property (include year, make, model, and serial number):
Location Address of Building

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Address of Business Personal Property

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What insured perils are requested?
If other, please state the perils requested:
What limit is requested on the Building coverage?
What limit is requested on the Business Personal Property coverage?
What limit is requested on the Scheduled Property coverage?
What limit is requested on the Business Income coverage?
What valuation is requested on the Building coverage?
What valuation is requested on the Business Personal Property coverage?
What valuation is requested on the Scheduled Property coverage?
Is a loss payee requested?
Loss Payee
Are the name(s) and address of the Loss Payee the same as what you entered previously for the Certificate Holder?
Please state the name of any Loss Payee requested:
Address of Loss Payee

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Loan Number
Please select the type of endorsement requested by the Loss Payee:
If Other, please state the type of endorsement requested:
Certificate Completion
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 Certificates, insurance requirements, contracts, and so forth.

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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:

MonthDayYear
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:
Should be Empty:

Certificate Request Form

Basic Information

Loss Payee

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: