Company Information-19
Company Name
Attn
Your Name
Phone
Ext
Certificate Holder
(Provide name, address and all pertinent information)
Name
Name as Additional Insured
City,State, Zip
Attention Of
Phone
Fax
Coverage Information -
We will evidence all coverages unless you specify otherwise)
General Liability
Automobile
Umbrella
Workers' Compensation
Property
Other
Certificate Holder's Interest -
(Important if named as Additional Insured)
Owner
Mortgagee
Lessor
Franchisor
General Contractor
Political Entity
Other Interest
Describe Operations, Equipment, Vehicles, Other -
(Provide job locations, property locations, loan numbers, etc.)
Cancellation Clause if Other than 30 Days -
Except 10 Days for Non-Payment of Premium
Days Requested:
Other Special Terms and Conditions -
(List any important exclusions or endorsements required)
Completed Certificate
Indicate distribution of the Certificate)
Mail/Fax Copy to Certificate Holder
RUSH Issue (
within 2 hours
)
Mail/Fax Copy to our office
Standard Issue
E-Mail to:
Send a copy of this form to a 3rd person name:
email:
Additional Comments:
Click the Continue button to send this form to SullivanCurtisMonroe Insurance Services.
You will be able to print your copy on the next screen.