Certificate Request Form

Documentation Provided by Certificate Holder
Insured Business *

IE, the business that has an insurance policy with Parker, Remsen & Sullivan.
Person Requesting Certificate on behalf of the Insured First Last
The owner or employee of the company who has a policy with PRS. Not the certificate holder.
Contact Phone * - (###) - ### ####
Contact Email
Party Requesting Proof of Insurance - CERTIFICATE HOLDER
*

Write the certificate holder's name as it needs to appear on the certificate.
CERTIFICATE HOLDER'S Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
What is the CERTIFICATE HOLDER'S interest? *

Why do they need a certificate? Some examples: Landlord, Leasee, Mortgagee, Contractor or Sub-Contractor.
Description of work to be performed by the Insured for the Certificate Holder:
Location of work performed by the Insured for the Certificate Holder:
Additional wording to be included on the certificate:
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If requesting to be listed as an additional insured, do you have a written contract? Yes No
If requesting to be listed as an additional insured, contract or lease #:
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We can fax, email and/or mail requested certificates to the insured. Check as many as apply: * Fax to Insured Email to Insured Mail to Insured Do Not Send to Insured
We can also fax, email and/or mail requested certificates to the certificate holder. Check as many as apply: * Fax to Certificate Holder Email to Certificate Holder Mail to Certificate Holder Do Not Send to Certificate Holder
If you have selected to have the certificates faxed or emailed, please provide the emails and/or fax numbers here:
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When do you need the certificate? *
Type the letters you see in the image below.

Certificate Request Form

Certificate Request Form

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