CSIS Insurance

Cerificate Request

Request for Certificate of Insurance

A Certificate of Insurance is a document that provides written evidence that an individual is participating in a health or group life insurance program or employee benefit plan. It is common among group programs that the employer or sponsoring organization are the only ones that receive a complete copy of the insurance policy. Members such as employees or union workers, receive Certificates of Insurance.

1. Name and Contact Information

Name of POLICYHOLDER (Business Name)

* Your Name

* Phone
Fax

* E-mail Address

2. Certificate Holder -

Party whom is requesting proof of insurance from you.

Name

Street Address
City
State	Zip

3. Job Address -

This information must be completed if this is an additional insured request

Street Address
City
State	Zip

Approximate Start Date of Job	Projected Finish Date of Job	Type of work YOU will be performing	Contract Value (Gross Dollars)

4. Does the Certificate holder require being listed as an ADDITIONAL INSURED?

Yes There may be a charge by the insurance carrier for this.

5. How do you want the Certificate delivered?

Fax

Mail to, if different from above

6. Comments - Special Wording/Insurance Requirements

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LICENSE #: OD80851

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