|
Certificate
Request Form
Go to HOME Page
"ENTER" KEY
WILL SUBMIT INSTANTLY. Use "TAB" key or MOUSE to scroll through then
Click "Submit"
Questions / Problems, call: (412) 271-8888
|
CERTIFICATE
HOLDER INFORMATION
- Below is not for your business's info. Enter
information for the entity which is requesting the certificate -
( All
information is required ) |
| Entity
Name |
|
| Entity
Name (add'l space) |
|
| Address |
|
| Address
(add'l space) |
|
| City,
State, Zip |
|
| Reason
for Certificate |
Permit
or License Grantor
Use
of Your Services or Products You Provide
Vendor
(sells your services, products, or trips / tours)
*
Use
of Land
*
Landlord,
or Manager of Premises
* If "Use of Land" or "Landlord / Manager of Premises", 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
------------------ |
| |
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 ?
|
| Is
there a written contract or agreement 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
could
extend liability coverage from your policy (defense costs & possible
claim payment) to that entity. |
| Applicable
Lines of Insurance? Check all which apply, only if known. |
General
Liability
Auto
Liability
Umbrella /
Excess
Employers
Liability (Work Comp)
Professional
Liability (E&O)
Other
(ie Bond, etc. Use Add'l Comments below to define if necessary.) |
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
Questions: (412) 271-8888
Otherwise, "Submit" below
|