Request a Certificate of Insurance

 

Please fill out the following information and we will send a certificate shortly. If you have a copy of the contract agreement, please email it to neckermaninsurance@neckerman.com.

 

Your Name

 

Name of Your Business

 

Your Email

 

Certificate Holder Information

 

Name of Company Requesting Your Certificate

 

Their Contact Name

 

Their Address

 

Method of Delivery

Mail
Fax
Email

 

Contact Info For Above Method

 

Reason for Certificate

 

Your Relationship to the Certificate Holder (i.e. Landlord? Contractor? Work Performed for Your Customer?

 

Project Description (if any) Name/Number/Address

 

Do you have a contract or agreement in place? Does it require any of the following?

 

Additional Insured (check all that apply)

General Liability
Work Comp
Auto
Umbrella

 

Waiver of Subrogation (check all that apply)

General Liability
Work Comp
Auto
Umbrella

 

Primary/Non-Contributory (check all that apply)

General Liability
Work Comp
Auto
Umbrella

 

Are specific limits or special coverages being requested in the contract agreement?

Yes
No

 

Special Instructions