Certificate Request

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(412) 271-8888 Questions / Problems

Account Name (Your Account Information)
City, State
Person Requesting Cert.	Email or Phone:

CERTIFICATE HOLDER INFORMATION
- Enter information for the entity which is requesting a certificate -
( All information is required )

Name
Name (add'l space)
Address
Address (add'l space)
City, State, Zip
Reason for Certificate	Permit or License Grantor Use of Land (if applicable, provide address below and/or description of land) Landlord, or Manager of Premises --------------- If none of the above, complete below ------------------
	Explain the relationship between your company and the requesting entity? What services are being provided between your company and the requesting entity? Please be DETAILED. Dates of the job, service(s), trip(s) - If Applicable ?
Is there a written contract between you and the requesting entity?	Yes No
Is Certificate Holder to be named as an Additional Insured?	Yes No Do not check "Yes" if you are not sure. Adding an entity as an Additional Insured (checking "Yes") may result in a premium charge to you, as this will extend liability coverage (defense costs & possible payment of a claim) to that entity, paid from your policy.

PROCESSING INSTRUCTIONS

Send to Certificate Holder by? Snail Mail Fax #?
Email....Address?

Do you need a copy? If yes, by: Snail Mail Fax #?
Email....Address?