Request for Certificate of Insurance

Third Party Administrators

Please complete this form to request a Certificate of Insurance. Once submitted, the Certificate will be delivered within two business days. If you require a rush, please include your deadline in the Comments section at the bottom of this form.

( * ) indicates required information

POLICY HOLDER CONTACT INFORMATION :

Firm Name*

Phone *

(format: 9259348500)

Contact Name *

Email *

CERTIFICATE HOLDER INFORMATION:

Certificate Holder Name*

Attention *

Address *

City *

State *

Zip *

Phone

(format: 9252952510)

Fax

(format: 9252952510)

Project Name and/or Number

CERTIFICATE REQUIREMENTS:*
Certificate holder requires certificate(s) showing coverage for (Please check all that apply)

GENERAL LIABILITY
Limits:	Use Current	Specify Other Limits:
Additional Insured:	Yes	No
Name of Additional Insured/Waiver in Favor of:

AUTO LIABILITY
Limits:	Use Current	Specify Other Limits
Additional Insured:	Yes	No
Name of Additional Insured/Waiver in Favor of:

WORKERS' COMPENSATION/EMPLOYERS' LIABILITY
Waiver of Subrogation:	Yes	No
Waiver of Subrogation in Favor of:

UMBRELLA
Limit:

PROFESSIONAL LIABILITY
Per Claim Limit:
Aggregate Limit:

DELIVERY OPTIONS
Please select which delivery options you would like us to use.

TO POLICY HOLDER:
	Email
	Fax
	Mail

TO CERTIFICATE HOLDER:
	Email
	Fax
	Mail
	Do Not Send

ADDITIONAL INFORMATION/COMMENTS:

*If you have additional documents to include, please email them to
TPAprogram@HeffINS.com