Rio Grande service office: |
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Your desired office of service:
* REQUIRED (please select one before continuing)
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Policy Holder Information:
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Name On the Policy (you, the Insured): |
*REQUIRED |
City: |
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State: |
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Best Phone Number: |
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Your (Insured's) Email: |
*REQUIRED |
Email to send certificate to: |
*REQUIRED |
Insurance Company: |
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Policy Number, if known: |
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| How to send certificate: *REQUIRED |
Above Email
Fax
Pick up at agency office above |
If by fax, fax number to send to: |
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To whose attention to send to: |
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Info required for each certificate: |
Certificate holder EXACT name: |
*REQUIRED
(sometimes known as "Insuring Clause" - you may copy and paste name and address in this box) |
| 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
I Don't Know - please contact me to discuss this
Other (describe completely below)
Evidence of Property (building) Insurance (Homeowners)
Evidence of Property (building) Insurance (Commercial)
Evidence of Personal Property (equipment) Insurance (Commercial)
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Certificate holder mailing address: (if not entered in the insurance clause box above) |
*REQUIRED |
Certificate holder mailing city, state & zip: |
*REQUIRED |
Loan number, if any : |
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Is a "CG2026" or other named-on-policy form 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) This option will
cost you an increase in your premium. |
YES
NO |
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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
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Any other special request or notes on above:
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