Certificates

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:

Issue Certificate To
Certificate Holder:
Individual/Attention:
E-mail:
Fax:
Address:
City:
State:
Zip Code:

Specific Job Information
Job Name/Contract No:

Provide Specific Contract Requirements
(OR send requirements to certificates@cavignac.com / fax #619-234-8601)

Include the Following Coverages
General Liability
Automobile Liability
Workers Compensation
Professional Liability
Excess Liability/Umbrella
Property
Other

List Certificate Holder as Additional Insured on
General Liability
Automobile Liability
Other required additional insured entities:

Include the Waiver of Subrogation Endorsement On
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
Certificates will be issued one working day after receipt by our office unless special forms are needed. Our certificate department will contact you if any forms require prior approval or if non-standard charges will apply.
Certificate should be sent to (select one):

Certificate Holder and your firm
Your firm only
Other