Service Center
Additional Insured or Certificate Request Form
Name of Person | Company Completing this Form:
*
Please enter your name here.
Email of Person Completing this Form:
*
Please choose the service being requested:
*
Certificate Holder
Additional Insured
1. Certificate Holder or Additional Insured:
Please note that this section MUST be complete.
Name:
*
Street Address:
*
City:
*
State:
*
Zip Code:
*
Phone Number:
###
-
###
-
####
Fax Number:
###
-
###
-
####
Email:
2. Insurance Requirements: Please note that if specific insurance requirements have been provided for this request, please fax them to: 800-209-9298. Further comments may be left in the box below.
3. Please provide a description of the work you will be performing:
*
This MUST be complete.
4. Type of Project:
*
New Residential Construction
Residential Remodeling (non-structural)
Residential Remodeling (structural)
Commercial T.I.
New Commercial
Pulling Permit
Landlord Request
5. Work to Involve:
*
Condos
Custom Homes
Tract Homes
Apartments
Government Projects
Hospitals
Airports
Schools
Retirement or Group Home
None of Above
6. Give Full Project Name & Job Address:
7. Have you signed a contract for this project?
*
Yes
No
List all Trades to be Performed:
9. Will you hire sub-contractors on this project?
*
Yes
No
10. If yes, what trades?
11. Your employee payroll on this project:
*
12. Contract Amount (Gross):
*
13. Estimated start date:
14. Estimated end date:
Electronic Signature: Please print full name and title:
*