Insurance Certificate Request Form

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Image Field
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Policy Holder's Name and DBA* This field is required.ex: John Smith, ABC Company, Inc.
Name of Insured (YOUR business)
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Your Policy Number
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Your E-mail Address* This field is required.Example: myname@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Requested by (Your First/Last Names)* This field is required.YOUR first & last names
Your First and Last Names
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Name and Address of Certificate Holder (Person or entity asking you for insurance)* This field is required.Complete address of PERSON/COMPANY ASKING FOR CERTIFICATE (street, city, state, zip).
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Email or Fax of Certificate Holder
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Does the Certificate Holder want to be named as Additional Insured?* This field is required.
Yes
No
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Additional Insured Name(s)
Please list names of ALL Additional Insured(s); separate additional names with a comma or semi-colon.
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Is there a contractual obligation to name the above additionally insured (If no, explain why needed)?* This field is required.
Please Select
Please Select
Yes
No
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If no, explain why needed?* This field is required.Is there a contractual obligation to name the above additionally insured (If no, explain why needed)?
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Detailed Job Description; describe the work the named insured will perform for the additional insured* This field is required.10 words or more - Example: Room addition, Framing Work, Interior electrical and painting work for office or commercial spaces in Orange County
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What is the requested Additional Insured's relationship to you? (General Contractor, Investor, Property Manager etc.)* This field is required.What your client/contractor doing (primary business activities)?
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Is the additional insured involved with NEW construction of condominiums, tract housing, subdivisions, townhouses or apartment buildings:* This field is required.
Yes
No
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Does the additional insured maintain their own insurance to cover their own exposures? If not, certificate will NOT be processed.* This field is required.
Yes
No
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Job/Project Location* This field is required.Required unless for various locations and also required for all new custom homes and commercial buildings. This is also required if the work is being done for an individual unit owner. If “Various Locations” – must list city(s) or county(s).
For “Various Locations” – privide city(s) or county(s)
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The job is:* This field is required.
Please Select
Please Select
Industrial
Residential
Commercial
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For residential Jobs* This field is required.
Please Select
Please Select
Remodeling
New Construction
Repair and Service
Room Additions
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If the job is NEW residential construction, is it condominiums, tract housing, subdivisions, townhouse, tract housing or apartment buildings ?* This field is required.
Yes
No
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Is the job work for a construction defect claim?* This field is required.
Yes
No
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COMMENTS (do you need special endorsements and/or wording; do you need to list your commercial auto, workers’ comp or other policies?)Request here any additional changes to the policy, such as adding Waiver of Subrogation or listing multiple policies on one certificate.
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Attach and Upload DocumentsUpload copy of insurance requirements, contracts, etc.
Drag and drop files here
Select files to upload
Max. file size: 14.9MB
Copy of contracts, detailed insurance requirements, etc.
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Image Field
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