Certificate of Insurance Request

Requestor Information

Company Name:*

Your Name:*

Email Address:*

Phone Number:*

Fax:

What is your relationship to the named insured?*

Insured Information

What is the name of insured?
(Name shown on policy)*

Certificate Holder Information

Certificate Holder Name:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Email Address:

Phone:

FAX Number:

How should we send the certificate to the holder? Please be sure you have provided FAX or Email.*

Email Fax

Attention of:

If other, please list:

Additional Insured

Is the certificate holder requesting additional insured status?*

Yes No

Is there an executed written contract requiring an additional insured?*

Yes No

Additional Insured:

Additional Insured Address:

For which lines would the certificate holder be named as additional insured?

General Liability - with Products/Completed Operations General Liability - without Products/Completed Operations Commercial Auto Product Liability Umbrella

Special Instructions

Start date of job:

When do you need the certificate by?

Please list any special instructions or requirements:

Please list the contract or job number if you need it on your certificate.

Waiver of subrogation requested (check if applicable)

Waiver for commercial automobile Waiver for general liability Waiver for workers' compensation

State(s) where work is being performed:

Payroll for this job ($)

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

SMS Opt In

I agree to receive SMS text messages about insurance and related services from Keller-Brown Insurance Services at the phone number provided above. The SMS frequency may vary. Message & data rates may apply. We cannot guarantee delivery of information to your mobile device. Text HELP to 717-895-8979 for assistance. Reply STOP to opt out of receiving SMS text messages. Please review our Privacy Policy here and Terms and Conditions here. *

Yes No

File Upload

If you have any documents to upload and attach to this form. Please upload them here: (Optional):

Click here to attach a file to this form

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to complete this request based on the information you provide.

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