(changes will be effective upon confirmation by a King & Neel representative)


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(* means required)

 

  * Your Business Name  
* Your Name 
      * Phone 
 * Email Address 
  Fax Number

 * Effective Date of the Change

 

 

Description of the Certificate Holder:

* Certificate Holder Name

  

* Street Address

  

Street Address #2

  

* City

    State   Zip               

 

Certificate Holder is to be named as:

 Additional Insured

(if required by written contract)

 Loss Payee
  Mortgagee
   

Additional Insureds

(other than the Cert Holder)
 

Will fax copy of insurance requirement section of the contract (if applicable)

 

Show the following coverages on the certificate:

 

General Liability

 Property
 

Automobile

 Umbrella
 

Workers Compensation

 Other: 

 

Purpose of the Certificate: 

  Specify, if Other: 

Contract No. (if applicable)


 

Description of Job, Location or Reason for the Certificate
 Is this an Owner Controlled (OCIP) Project?    Yes

OTHER COMMENTS OR REMARKS?

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