Certificate of Insurance Request Form
Your Firm Name:
Your Name:
Certificate Holder:
Attention:
Address:
City
State  
Zip Code:

Is the Certificate Holder requesting to be named as an additional insured on your General Liability coverage (if applicable)?
YES
NO 		(Note that most policies require that this request be part of a written contract or agreement in order for the additional insured coverage to apply.)
If Yes, indicate who should be listed as an additional insured if other than the Certificate Holder:
Please indicate which coverages should appear on the Certificate:
General Liability   Umbrella (Excess) Coverage
Automobile Liability   Professional Liability (E&O)
Workers Compensation OR All policies should be listed
Email/Fax
Certificate to:
Your firm Email:
    Fax# :
Certificate Holder Email:
    Fax#:
Other: Email:
    Fax#:
Other Instructions:

 

 

 

  
 
Submitting this form does not bind the insurance company or agency to sell nor the applicant to purchase the insurance.

  
 

Euclid Insurance I 234 Spring Lake Drive I Itasca, IL 60143 I Phone: 630-694-3700 (ask for a member of the A/E Team) I Fax: 630-773-4075 I E-Mail: ae@euclidinsurance.com
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