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General Liability Certificate Request
Please fill out the form below and allow 24 hours for processing.
(* = Required Field)
Insured Fax #*:
Date of Request*:
Certificate Holder Information Only:
Certificate Holder Name*:
Description of Operations
(include project name/number):
Additional Insured Request (If required by signed contract):
Name & Address of Additional Insured:
Description of Operation and Location:
Relationship/Interest to the Named Insured:
Is there a written contract between the Named Insured and the Certificate Holder?
Does the Additional Insured maintain Primary Insurance to cover exposures at the job site?
Optional Endorsement - MUST provide copy of contract &/or requirements:
Primary/Non-Contributory Wording GL-295s
Waiver of Subrogation CG2404
Addition Insured with Completed Operations (CG2037 commercial work only)
Addition Insured CG2010 ongoing operations only
Additional Insured Blanket CG2033
Addition Insured CG2503 designated construction project
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