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Request a Certificate/Auto ID



Is the Certificate Holder requesting to be named as an
additional insured on your General Liability coverage (if applicable)?

Yes No


Please indicate which coverages should appear on the Certificate:

General Liability
Umbrella (Excess) Coverage
Automobile Liability
Professional Liability (E&O)
Workers Compensation
All Policies Should Be Listed
Property Certificate


Email/Fax Certificate to:

Your Firm
Certificate Holder
Other:



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