marrs maddocks || Certificate of Insurance Request Form

Certificate
Requested By

Name:

Email:

Insured Name:

Issue Certificate To

Certificate Holder:

Individual/Attention:

Address:

City:

State:

Zip Code:

Job Name/Contract No.:

Coverages

Include the Following Coverages:

Additional
Insured

List the Certificate Holder as Additional Insured on:

General Liability	Automobile Liability
Other (please specify)

Waiver of
Subrogation

Include the Waiver of Subrogation Endorsement on (may require prior approval):

General Liability

Workers' Compensation

Our Service Standards & Procedures

Check Only One Box:

	Standard Service Certificates mailed to certificate holder and your firm one working day after receipt by our office.
	Other Service (Please describe requirements and "Need By" dates.):