Certificate of Insurance Request Form

Instructions

1. Certificate Holder/Company Name 

Certificate Holder name and address exactly as it should appear on certificate.

2. Coverage to be shown

Check all that apply: General Liability, Auto, Workers’ Compensation Umbrella/Excess Liability. If other coverage, please specify.

3. Certificate Holder Names as Loss Payee/Additional Insured

Check appropriate box if Certificate Holder is to be named as Loss Payee and/or Additional Insured.

4. If so, what is their interest? 

Loss Payee: Indicate the personal property for which the Certificate Holder holds title, loan note, etc. Additional Insured: Indicate if Project Owner, General Contractor, Landlord, etc.

5. If named as Additional Insured, is there a written contract?

Check appropriate box, if Certificate Holder is to be named Additional Insured. Often Additional Insured endorsements are not valid unless required by a written contract in place during the policy term, executed prior to any occurrence to which the insurance applies. Please call if you have any questions about your specific policy requirements. 

6. Name/Location of Job/Contract

Identify job/contract number used to differentiate projects, if any.

8. Job Start/End Date

Identify job start/end date.

9. Type of Job

Identify if work to be performed is Residential or Commercial in nature.

10. Description of Operations

Briefly describe work to be performed as pertains to this certificate request.

11. Is This a Wrap/OCIP Project?

Identify if project requirements enrollment into insurance program purchased or administered by another party, e.g. project owner. If “Yes”, indicate if General Liability and/or Workers’ Compensation coverages are provided.

12. Include Primary/Noncontributory wording?

Check “Yes” if required by Certificate Holder.

13. Include Waiver of Subrogation?

Check “Yes” if required by Certificate Holder, and identify all policies which should include a Waiver of Subrogation. Waiver requests may generate additional premium.

14. Special Instructions

Include any special instructions regarding certificate deliver (fax, e-mail, etc.), or any company-specific Additional Insured language, etc. from Certificate Holder.

OFTEN ENDORSEMENTS ADDING ADDITIONAL INSURED STATUS, PRIMARY WORDING AND/OR WAIVERS OF SUBROGATION ARE NOT VAILID UNLESS REQUIRED BY WRITTEN CONTRACT IN PLACE DURING THE POLICY TERM, EXECUTED PRIPR TO ANY OCCURRENCE TO WHICH THE INSURANCE APPLIES. PLEASE CALL IF YOU HAVE ANY QUESTIONS ABOUT YOUR SPECIFIC POLICY REQUIREMENTS. 

Please include with this Certificate Request copies of any written insurance requirements provided by the Certificate Holder.

Insured

  • *Often Additional Insured endorsements are not valid unless required by a written contract in place during the policy term, executed prior to any occurrence to which the insurance applies. Please call if you have questions about your specific policy requirements.
 

Name and Location of Job/Contract

  • *Often Waivers of Subrogation are not valid unless required by a written contract in place during the policy term, executed prior to any occurrence to which the insurance applies. Please call if you have any questions about your specific policy requirements.
 

Verification