Certificate Holder/Additional Insured Request Form Your Company Name * Email * Your Policy # * Does the entity need to be listed as just a Certificate Holder or are they specifically requesting to be listed as an additional insured? * Certificate Holder Additional Insured How is the entity related to you? * For example - contractor, subcontractor, landlord, required for city permit, etc. Start Date of Event/Project/Work * MM DD YYYY End Date of Event/Project/Work * MM DD YYYY Full Company Name & Address Company Contact Info - Name and email and/or phone number * If contractor/subcontractor - What work is being performed? If contractor/subcontractor - total value of job/project Thank you! These typically take up to 48 hours, depending on the insurance carrier.
