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CERTIFICATE REQUEST FORM

Attention: Please complete all required fields. A separate form is required for each Certificate of Insurance.
Certificate of Insurance delivery times vary between 1 to 3 business days contingent upon complexity of each certificate requested. Special Wording / Endorsements requests may prolong issuance up to 14 business days per underwriting guidelines while pending carrier approval.
For additional certificate assistance please contact customer support.

By requesting a Certificate of Insurance the user agrees to the following terms & conditions:

  1. Certificates of insurance must be requested PRIOR to commencing operations.
  2. Additional Insured endorsements must be requested PRIOR to commencing operations.
  3. Additional Insured endorsements can NOT be issued once the project has been completed.
  4. Fairbanks Insurance Brokers, Inc. is not responsible for the distribution of certificates to the certificate holder.
  5. Policy Holder understands that a certificate of insurance does not constitute a contract between the issuing
    insurer(s), authorized representative or producer, AND the Certificate Holder.
  6. Policy holder must comply with all local and state laws.
  7. Coverage is subject to policy terms and conditions.

By clicking, I agree with the above subjective and wish to proceed.

Policyholder's Information

Your Company Name *

Your Name *

Your Email *

Your Phone *

Certificate Holder Information

Certificate Holder Name *

Additional Insured Name

Certificate Holder Street Address *

Certificate Holder Suite Number

Certificate Holder City *

Certificate Holder State *

Certificate Holder Zip Code *

Relationship Between Policyholder and Certificate Holder / Additional Insured *

Certificate Requirements

Required Policies

Please check all that apply *
General LiabilityWorkers CompensationCommercial AutoExcess / UmbrellaOther

Other:

Required Endorsements

Please check all that apply

Additional InsuredWaiver of SubrogationPrimary WordingAdditional Insured (Completed Ops)

Other:

Upload Documents

Required Special Wording

Project Information

Project Name *

Project Number

Project Start Date *

Project Completion Date

Project Estimated Value *

Project Street Address

Project City

Project State

Project Zip Code

Operations Information

Please check all that apply *

New Construction (Ground Up)RemodelResidentialCommercialIndustrialService/Repair

Description of Operations *


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