Small Firm Quote
Online P/L Quote for Firms
Under $500,000 in Billing
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Certificate of Insurance Request Form
NOTE: Fields marked * are required.
Certificate Request By:
*
Email Address:
*
Insured Name:
*
Issued Certificate To:
Certificate Holder:
*
Individual/Attn:
*
Email:
*
Fax:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Job Name/Contract No.:
*
Include the Following Coverages:
*
General Liability
Automobile Liability
Professional Liability
Property
Excess/Umbrella
Workers Compensation
Other
List Certificate Holder as Additional Insured On:
General Liability
Auto Liability
Other
Include the Waiver of Subrogation Endorsement on:
General Liability
Automobile Liability
Workers Compensation
Cancellation Clause
Delete wording "endeavor to" and "but failure to mail..." from cancellation clause
Our Service Standards and Procedures
*
Standard Service
- Certificates mailed to certificate holder and your firm one working day after received by our office unless special forms are needed, which could result in a 3 to 5 day response.
Other Services
- Please describe requirements and "Need By" Dates:
Please Forward My Request To:
*
Karen Brinkley
Brian King
Kathy Kulcsar
Lisa Scholder
Tammy Johnson
