Cavignac & Associates

Certificate of Insurance Request Form

(Read our Notice of Privacy Policy)

Please Select One:
	New Certificate
	Renewal Certificate
	Revise Existing Certificate

Contact Information:

Certificate Requested By:

E-mail:

Fax:

Insured Name:

Issued Certificate To:

Certificate Holder:

Individual/Attn. (if applicable):

E-mail:

Fax:

Address:

City:

State:

Zip Code:

Specific Job Information:

Job Name/Contract No:

Provide Specific Contract Requirements:
(OR fax a copy of Contract Requirements to 619-234-8601)

Request for Contract Review

Include the Following Coverages:

General Liability

Automobile Liability

Professional Liability

Property

Excess/Umbrella

Workers Compensation

Other

List Certificate Holders as Additional Insured on:
(company charges may apply)

General Liability

Automobile Liability

Additional Entities

Include the Waiver of Subrogation Endorsement on:
(may require prior approval)

General Liability

Workers Compensation

Auto Liability

Cancellation Clause:

Delete wording "endeavor to" and "but failure to mail..." from cancellation clause

Our Service Standards and Delivery Options:

Standard Service
Certificates will be issued one working day after receipt by our office unless special forms are needed.

Certificate requested above should be sent to (check one):

	Certificate Holder and your firm
	Your firm only
	Other

Please Forward My Request To:

Valerie Jones

Katherine Marberry