Concord Insurance - Request a Certificate of Insurance

Request for Certificates of Insurance


Your Company Name
Requested by:

Please provide certificate holder's name/address (That is the person requesting the certificate from you)

Name:
Street:
City:	State: Zip:

What is the relationship to you? (ie: Landlord, customer, general contractor)

Relationship:

Provide location of work being done. If it is a general work being done throughout the year we need a description (ie: various carpentry projects being done for holder throughout policy period, renting equipment from holder)

Location:



Any special wording needed? (ie: Additional insured, waiver of subrogation). If so need a copy of the request.

Special Wording?

Copy of contract received? If so, will need to fax over (585-265-6055)

Any insurance requirements that the General Contractor has waived for our insured we need something in writing from the GC/cert holder that it has been waived.

Special mailing instructions?

Fax?	Yes No Fax Telephone #

Fax Attn to:

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