Certificate Request Form

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Questions / Problems, call: (412) 271-8888

 Account / Business Name
  (Your Account Information)
 City, State
 Person completing this form Email or Phone:

CERTIFICATE HOLDER INFORMATION
 
- Enter information for the entity which is requesting a 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 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 ------------------
   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
 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

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?

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


T.R.G.
Copyright © 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: July 28, 2010 .