Rio Grande Insurance

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Insurance Certificate/Proof Request Form

Your best insurance value in the Southwest

Rio Grande service office:
*REQUIRED (please select one before continuing)
Policy Holder Information:
Name On Policy/Insured:	*REQUIRED
City:
Best Phone Number:
Your Email to confirm with:	*REQUIRED
Email to send certificate to:	*REQUIRED
Insurance Company:
Policy Number, if known:
How to send certificate: *REQUIRED	Above Email Fax Pick up at agency office above
If by fax, fax number to send to:
To whose attention to send to:

Info required for each certificate:
Type of certificate : *REQUIRED	Additional Insured: Manager or Lessor of Premises (Also for conference or event location owners) Additional Insured: Owner, Vendor or Contractor Additional Insured: Designated Individual (costs you $50 each) Loss Payee (they own item that you will use) Additional Insured & Loss Payee Certificate Holder (Their name is shown on certificate for proof only, but they will not be named as an additional insured) Informational/Proof Only - no name needs to be on certificate Other (describe completely below) Evidence of Property (building) Insurance (Homeowners) Evidence of Property (building) Insurance (Commercial) Evidence of Personal Property (equipment) Insurance (Commercial)
Certificate holder EXACT name:	REQUIRED (sometimes known as "Insuring Clause*")
Certificate holder mailing address:	*REQUIRED
Certificate holder mailing city, state & zip:	*REQUIRED
Loan number, if any :
Is a "CG2026" required? (This means that insured requires that they must be specifically named on a form on the policy, and that the more "normal" 'blanket additional insured' endorsement is not acceptable - This is not common) Will cost you $50+ each	YES NO

Please describe certificate holder's relationship to the insured: e.g. Location being used, Event Holder, Landlord, Equipment rental house, Auto rental company, Government entity for a permit, First or second mortgagee, police or transportation division *REQUIRED

Any other special request or notes on above:

Online insurance certificate request for proof of insurance. Additional Insureds and Certificate Holders to be named on evidence of property insurance. Loss Payee and Blanket additional insureds for homeowners insurance and commercial business insurance. Locations, Managers, Lessors, Designated Persons, Owners, Lessees or Contractors.

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Rio Grande Insurance

Relax... Let us shop for you.

Insurance Certificate/Proof Request Form

Rio Grande service office:

Policy Holder Information:

Info required for each certificate:

Please describe certificate holder's relationship to the insured:

Any other special request or notes on above:

Website Design, Development, and Marketing by NET MAN