Account Name:

Requested By:

Email Address:

Phone Number:
() 

Fax Number:
() 

Certificate Holder:

Address Line 1:

Address Line 2:

City:

State:
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Zip Code:

Attention:

Email Address:

Fax Number:
() 

Required Coverages
(Select the appropriate coverages)
General Liability (Please provide job description below)
Workers’ Comp
Umbrella
Automotive Liability (Please provide description below)
Automotive Physical Damage (Please provide description below)
Property/Contents (Please provide description below)
Equipment (Please provide description below)
Other (Please provide description below)

Description for Certificate: (Please detail job description, job number, year, make model, VIN, serial number)

Additional Insured: GL Auto

Describe Interest of Certificate Holder:

Loss Payee
Mortgagee

Special Instructions
Primary
Non-Contributory
Waiver of Subrogation: GL Auto Workers’ Comp
Cancellation: (Please specify)
Other: (Please specify)

Handling Instructions
Email certificate to certificate holder at address listed above
Email certificate to certificate requestor (Email address)
Fax certificate to certificate holder at fax number listed above
Fax certificate to certificate requestor (Fax number)
Other delivery (Please specify)

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