Certificate of Insurance Form
Attn:
First Name:
Last Name:
Phone:
Fax:
Email:
Street:
City:
State:
Zip:
Line of Business (GL/WC/Property/Inland Marine/Umbrella)
Designation of Holder (Additional Insured/Mortgagee/Loss Payee etc)

If Additional Insured, is there a written contract between you and the certificate holder requiring Additional Insured Designation?  If yes, Please explain in the comments section.  Please note Additional Insured Designation is not available on Worker’s Compensation
Comments:

 

 
"Please understand that there is no coverage bound until you receive confirmation in writing from Hurst-Weiss Insurance."
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