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| Person Requesting * | |
| Your Company Name: * | |
| Insured Entity Name: | |
| Requester Email Address: * | |
| Requester Phone Number * | |
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| Holder Name * | |
| Holder Email: * | |
| Holder Address: * |
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Is Certificate Requested for a Certain Vehicle, Equipment, Property, or Project? |
| If so please indicate in space provided below: | |
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| Additional Insured's?** | |
| Loss Payee?** | |
| Wavier of Subrogation?** | |
| Same as Certificate Holder? | |
| If not the same, it should read as follow: | |
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**Additional premium charges may be required for each additional insured, loss payee, or wavier of subrogation. Any requests for special coverage such as additional insured, waiver of subrogation or any special requirements will be referred to your insurance company underwriter for approval, which may delay the issuance of the certificate. You will be contacted by our office, once any approvals are received. |
| Please list any special certificate instructions below: | |
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All certificate request for current coverage will be processed within 24 hours of reciept of the request (excluding weekends and holidays) Preferred Delivery Method |
| Email Address * | |
| Facsimile: | |
*A copy of this certificate will be sent to requester’s email address above |
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