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YOUR “ONLINE” CERTIFICATE of INSURANCE

Request Form

INSURED:
Requested By:   Phone Number:

Certificate Holder

COMPANY NAME:
Address:
City, State, Zip:
Fax Number: Attention To:
PROJECT NAME: PROJECT #:
PROJECT Location or Address:
Description of PROJECT:
If NEW ("Ground Up") Construction -
Single-Family, Custom Home Tract Home Apartments(incl. Conversions)
Condos/Townhomes Commercial Building


Is an ADDITIONAL INSURED Endorsement REQUIRED? YES NO bluestar
If If so, please provide the following -
PROJECT Start Date: / /
Completion Date: / /
PROJECT COST: $
Additional Insured’s relationship to you: General Contractor
Property Owner/Manager Lender Landlord Retail Supplier
Home Warranty Referral Firm Municipality
Other
Multiple Project Locations? Yes No

If yes, indicate territory, description of work, avg. job cost & expected frequency

Number of Employees at Jobsite:
Type of work SUBBED OUT:
Percentage of work SUBBED OUT: %
Written Contract w/ Additional Insured? Yes No
Does Additional Insured maintain PRIMARY Insurance on project? Yes No
Is “PRIMARY WORDING”, “WAIVER of SUBROGATION” or a specific A/I version/edition required? Yes No
Any additional “SPECIAL WORDING” required? Yes No
If so, please provide the Certificate Holder’s SAMPLE!

bluestarThere may be ADDITIONAL PREMIUM DUE for this Endorsement !

Unless specifically requested the Certificate of Insurance provided will include ALL coverage(s) written through CC Roy Insurance Brokers, Inc.  In most cases, your Certificate Insurance will be processed the same day received (if received by 12:00pm).  Many Additional Insured Endorsements must be ordered from your Insurance CARRIER and may take up to ten (10) business days to process.        THANK YOU!