Request A Certificate

1. Certificate Type. Please Select One:

New Certificate
Renewal Certificate
Revise Existing Certificate

2. Contact Information:

Insured name:		*
Certificate requested by:		*
Requester e-mail address:		*

3. Issue the Certificate To:

Certificate Holder:		*
Address:
Individual/Attn to:
Project/Job Name:

Certificate Delivery Information

4. Please Specify Recipients Below:

If your request does not need any of the following optional specification items, you may submit it now.

or continue below with optional specification items.

Optional Specification Items

5. Include the Following Coverages and Limits:
(Mark a limit only if you want to represent a limit less than you have purchased)

	All Coverages at Purchased Limits
-or-
	Coverage	Limit
	General Liability
	Automobile Liability
	Workers Compensation
	Excess/Umbrella Liability
	Professional Liability
	Property
	Other:

6. Do you have a written contract requiring you to name the Certificate Holder as Additional Insured?

Yes No

If Yes, Please Specify which Coverages are to be Included:

General Liability Automobile Liability

Does your contract require that we attach the Additional Insured Endorsement?

Yes No

Please list all Additional Insureds Names/ Entities that need to be included on the Certificate:

1.	(Certificate Holder, from item 3)
2.
3.

Please Note:
Naming a Certificate Holder as Additional Insured on a Professional Liability Insurance Policy is not available or allowable.

7. Does the Certificate Holder Require a Waiver of Subrogation?

Yes No

If Yes, Is the Waiver of Subrogation for (Check all that Apply):

General Liability
Workers Compensation
Automobile Liability
Excess/Umbrella

Does the Certificate Holder Require a Waiver of Subrogation Endorsement as Specified in Your Contract?

Yes No

8. Does the Certificate Holder Require that they be Named with Primary and Non-Contributory Additional Insured Language as Specified in Your Contract?

Yes No

If Yes, is an Additional Insured Primary Endorsement Required?

Yes No

9. Special Instructions or Specific Contract Information (specify in box below). You may also fax a copy of specific contract requirements to the attention of Certificate Department at 360-598-3703.

10. Cancellation Requirements:

10 Days 30 Days

Does the Certificate Holder require the following Language to be deleted as Specified in Your Contract? "Delete the wording 'endeavor to' and 'but failure to mail.' from cancellation clause"?

Yes No

When you are finished filling out the certificate request form, send your form to us by pressing the button below.

Certificate Delivery Information

Optional Specification Items