Frenkel Construction & Professional Services Group -- Certificate of Insurance Request Form

CERTIFICATE REQUEST

This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

* Indicates Required Field.

Insured Information

*Insured Making Request:

Address:

City:

State: Zip:

*Phone:

Fax:

*Email Address:

Recipient Information
Please issue Certificate of Insurance to the following:
*Name:
*Address:
*City:	State: Zip:
*Job Reference:
Do you want Certificate faxed?:	Yes No Fax #:
*Attention:

Certificate Information

*Policies to Reference:

Auto	Property	Professional Liability
Umbrella	General Liability	Workers' Comp.

*Unless specified, all current policies on file with Frenkel will be indicated
on the certificate.

Additional Insured:

May incur additional premium charge.
General Liability Auto

Waiver of Subrogation:

May incur an additional premium charge.
General Liability Workers' Comp.

Special Instructions

Please give any special instructions you feel appropriate for this certificate.

*Please advise of the insurance requirement if special items are needed.

Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.
*The original will be mailed directly to the certificate holder unless otherwise instructed.