Whitney Group - Certificate Request Form

Certificate Request Form

Insured Name:
Name of Requestor:
Email Address of Requestor:
Date of Request:
Name of Certificate Holder:
Address of Certificate Holder:
City:
State:
Country:
Zip Code:
Fax to Certificate Holder:	Yes No
Fax Number:
Attn:
Email to Certificate Holder:	Yes No
Email Address:
Fax to Insured:	Yes No
Email to Insured:	Yes No
Is Certificate Holder to be named as an Additional Insured?	Yes No
If so, please fax a copy of the insurance section of the contract to our office with this form.
Is a Waiver of Subrogation required in favor of the Certificate Holder?	Yes No
If so, please fax a copy of the insurance section of the contract to our office with this form. (Note that additional information and/or applications may be required.)
Special Instructions and/or Requirements:
Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.