WORKERS’ COMPENSATION CERTIFICATE REQUEST

Client Name:

Person Requesting:

     Certificate of Insurance     Shows coverage   

Other insurance requirements which may be placed on you by the virtue of contracts you enter into may give the insured holder one of the following benefits on your policy, and may raise your premiums substantially.

      Additional Insured              
Adds the holder as an Additional Insured onto your policy

     Waiver of Subrogation        
Makes it impossible for your insurance company to sue the Holder’s insurance company for any claim, even if they were responsible for the loss.

      30 Day Notice to Cancel       
Amends your policy to force your insurance company to give the Holder 30 days notice of cancellation (for any reason, including non-payment)…the normal notice is 10 days.

CERTIFICATE HOLDER

Holders Name (complete):

Address:

City:
 
State:
   
Zip Code:
 

Project Name or #:

Fax and/or E-mail to:
   

Attention: