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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