All Certificates Will Be Issued Within 48 Hours Upon Receipt of the Completed Request

Page 2

Email to:

Nicole,

Or Fax to: 212-948-0015

All certificates will be issued within 48 hours upon receipt of the completed request.

.Rush certificates should state RUSH in subject line of email and should be completed within 4 hours

COMPLETE INFORMATION BELOW FOR ISSUANCE OF CERTIFICATE
Date requested: / Date Needed: / ASAP
Requested by: / Do you require a copy? No Yes
Phone: / Fax
Fax: / Email
Email:
Named insured to be shown (other than C of C):
Certificate Holder / Coverage to be Evidenced on Certificate
Company Name / COVERAGES
General Liability
Automobile Liability
Workers Comp,
Umbrella/Excess
Liability
Other:
______/ PROPERTY COVERAGE
Property
Real Property (Building)
Personal Property
(Contents, equip, etc.)
Betterments and Improvements
Rental Value
Other (List or attach Contract)
Attention:
Address:
Holder’s Interest (to be shown on certificate)
Evidence Only Additional Insured
Loss Payee
Mortgagee
Description:
If Property Certificate Requested Include Detailed Description of Property, Location of Property, Value to be insured and Effective and Expiration Dates of Certificate.
Special Instructions:

Distribution of Certificate

How should the certificate be sent?
DO NOT SEND TO CERTIFICATE HOLDER
Regular Mail:
Email to:
Fax to: