The Schneider Group - Financial & Insurance Solutions

Certification Request

INSURED:

* Coverages:		General Liability
		Property
		Automobile
		Workers Comp
		Umbrella
		Other

		If other, please specify:


* Certificate Holder Name:

* Street Address:

* City, State, Zip:

Attention:

Fax #:

* Requested by:

* Email Address:

Special Instructions:

This is Standard Certificate Wording (no charge for this): With respect to work performed by the named insured on behalf of the certificate holder during the policy period (10 Days Notice of Cancellation).

If there is a contract, please review it and indicate below if the Certificate Holder requires any of the following (there may be an additional premium charge to you):

		Additional Insured
		Additional Insured Including Products & Completed Operations
		30 Days Notice of Cancellation
		Waiver of Subrogation
		Primary and Non-Contributory
		Specific Project
		Per Job Aggregate
		Any and All Jobs
		Loss Payee
		Mortgagee