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Certificate
Request Form
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Questions / Problems, call: (412) 271-8888
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CERTIFICATE
HOLDER INFORMATION
- Enter
information for the entity which is requesting a certificate -
( All
information is required ) |
| Entity
Name |
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| Entity
Name (add'l space) |
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| Address |
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| Address
(add'l space) |
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| City,
State, Zip |
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| Reason
for Certificate |
Permit
or License Grantor *
Use
of Land
*
Landlord,
or Manager of Premises
* If
"Use of Land" or "Landlord
/ Mgr Prem's", please list the full address of the space / plot
of land, or an area description if no address is available
for the land this pertains to:
--------------- IF NONE OF THE ABOVE, complete below
------------------ |
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Explain
the relationship between your company and the requesting entity? What services
are being provided between your company and the requesting entity?
Dates of the
job, service(s), trip(s) - If Applicable ?
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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. |
Applicable
Lines of Insurance?
Check all which apply, only if
known. |
General
Liability
Auto
Liability
Umbrella
Employers
Liability (Work Comp)
Professional
Liability (E&O)
Other |
Additional
Comments / Information
PLACE INITIALS HERE TO
VALIDATE FORM
NOTE: Some entity's have unique wording / coverage in their
requirements. If you are not sure that your
insurance coverage is adequate, please forward a copy of the insurance
requirements to us for review:
Email Copy to:
insurance@thompsongusic.com
or Fax Copy to: (877) 271-8898
Otherwise, "Submit" below
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