Certificate Request Form

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"ENTER" KEY WILL SUBMIT INSTANTLY.   Use "TAB" key or MOUSE to scroll through.
 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 address of the space,
           or address / plot of land which is rented / leased that this certificate 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?  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?

Additional Comments / Information


Please place initials here to validate form then click "Submit" below.

T.R.G.
Copyright © 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: January 18, 2010 .