Certificate of Insurance - DOC

					                           Certificate of Insurance

Insured’s Name: _________________________________ Phone (______)_____-_______

           d/b/a: _________________________________ Fax           (______)_____-_______

           Email: ________________________@_______

Types of Insurance to be on certificate (Check all that apply):
              General Liability                                     Workers Compensation
              Business Auto                                         Umbrella/Excess Liability
              Professional Liability                                Liquor Liability
              Other: __________________

Special coverages requested (Check all that apply):
              Additional Insured                                    Primary Basis
              Per Project Aggregate                                 Non-Contributory
              Per Location Aggregate                                30 Days Notification
              Other: __________________
What services are you providing or what activities are involved? (Give job number if applicable):

_______________________________________________________________________

Is there a specific event day or dates you are providing your services? _______________

Is the Certificate Holder requesting any special wording on the certificate? If yes:

_______________________________________________________________________

Certificate Holder Information: (* required information):

       *Name         ___________________________________________________

                     ___________________________________________________

       *Address      ___________________________________________________

                     ___________________________________________________

       *City         _____________________*State _______ *ZIP ______-_____

       *Fax    (______)_______-_________        Phone (______)_______-_________

       *Email ____________________@_________ Contact: __________________