Colling Insurance Services, Inc. - Request Certificates

Account Name *
Requested By*
Email Address*
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
Certificate Holder*
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Required Coverage

General Liability (Please provide job description below)Workers’ CompUmbrellaAutomobile Liability (Please provide description below)Automobile Physical Damage (Please provide description below)Property (Please provide description below)Other (Please provide description below)
Select the appropriate coverages.
Description for Certificate
Please provide a detailed description of project including address and contract cost. If automobile, property, or equipment provide year, make, model, VIN/serial number.
Additional Insured

GL(company fee may apply)
Describe Interest of Certificate Holder

General ContractorProject/Property OwnerDeveloper/Architect/EngineerLoss PayeeMortgagee
Special Instructions

Primary/Non-Contributory WordingWaiver of Subrogation:
If Waiver of Subrogation

GLWorkers’ Comp
Other Special Instructions
Handling Instructions
Where would you like the certificate sent?
Email certificate to requester

YesNo
Email to a third party
Fax Certificate

Area CodePhone Number
Other Delivery
Comments
Should be Empty: