Certificate Request

Date *

Company Name *

Your Name *

Email Address *

Certificate Holder Name *

List all "Additional Insureds" (if different than Certificate Holder)

Certificate Holder Address

(complete address, include zip code)

Attention

Phone Number

Email Address/Certificate Holder *Note: Include Certificate Holder address, even if you want this Certificate emailed to you directly

How to Send: Bolds will..... *

-----Email to Certificate Holder-----Email to you; you will send to Certificate Holder

Job Description or Location *

Additional Insured (required by contract)

-----Not Required by Contract-----YES - Policies requiring indicated below

If Yes, which policies (show below)

Workers Comp is not eligible

Primary Wording (required by contract)

-----Not Required by Contract-----YES - Policies requiring indicated below

If Yes, which policies (show below)

Workers Comp is not eligible

Waiver of Subrogation (required by contract)

-----Not required by contract-----YES - Policies requiring indicated below

If Yes, which policies (show below)

Per Project Aggregate-General Liability (required by contract)

-----Not required by contract-----Yes (General Liability)

OCIP (Owner Controlled Insurance Program)

-----Project is NOT an OCIP-----YES - Policies covered by OCIP shown below

If Yes, which policies are covered by OCIP (show below)

File Upload (pdf, jpg, jpeg) - Attachment 1 Camera picture of contract or lease is adequate

File Upload (pdf, jpg, jpeg) - Attachment 2

Other Instructions

COPY OF CONTRACT RECOMMENDED We recommend that you include a copy of your contract or agreement when additional insured coverage is required, or the job is covered by an OCIP. "Additional Insured", "Primary Wording", "Waiver of Subrogation" and "Per Project Aggregate" can only be provided if required by contract. A premium charge per certificate may apply

CERTIFICATE REQUEST FORM

BOLDS CLIENT INFORMATION

CERTIFICATE HOLDER INFORMATION

Verification