Certificate of Insurance Request

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This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

    INSURED INFORMATION

    Pawson Customer Name

    Address

    City

    Phone

    RECIPIENT INFORMATION

    Please issue Certificate of Insurance to the following:

    Name

    Address

    City

    Attention

    Job Reference

    Want Certificate Faxed?

    CERTIFICATE INFORMATION

    Policies To Reference *

    AutoGeneral LiabilityWorkers' Comp.UmbrellaEquipmentBuilders Risk

    *Unless you specify differently, Auto, General Liability and Workers' Comp
    will be the only policies indicated on Certificate (when applicable)

    Additional Insured


    If YES, specify which policies and give details

    Waiver of Subrogation


    If YES, specify which policies and give details

    30 day Notice of Cancellation

    YesNo

    SPECIAL INSTRUCTIONS

    Please give any instructions you feel appropriate for this certificate.