Prof Cert Req | Widerman & Company

Certificate Of Insurance Request

This form is for notification purposes only. Any change(s) you request (below) will not be binding until you receive confirmation from us. We will make every effort to contact you on the next business day. If we fail to do so, please call us accordingly.

Your Information

* Company Name:

* Your Name:

Certificate Holder Information

* Name:

Attention:

* Address:

* City:

* State:

* Zip Code:

* Reason For Certificate Request (If for a service, maintenance or construction contract,
please provide name of the job and location):

The Certificate Holder Must be Named As:

ADDITIONAL INSURED:

Is There A Written Contract?:

If YES, please explain/provide details on the Additional Insured requirements and any other insurance
provisions in the contract:

LOSS PAYEE:

Please describe the machinery, equipment or other property to be insured:

Handling Instructions

How do you want the certificate sent to the holder?:

SEND ME A COPY:

IMPORTANT NOTICE

                If you have signed a contract or will be signing a contract related to this certificate of insurance request,
                it is imperative that you review the insurance and indemnification provisions of the contract so that you can
                advise us of any spedific insurance requirements that must be met. Please contact us if you have any
                questions about the contract insurance requirements or your current insurance protection.
                Also, keep in mind that your attorney should review any contracts you plan to execute. Contracts may be
                worded in ways in which you or your company assume risks and liabilities beyond (outside) the scope
                of your insurance protection. Legal counsel may be needed to eliminate or reduce the risks associated
                with signing such contracts.

(*) Mandatory Fields