Your Name*
Your Company or Organization*
Your Email*
Your Phone Number*
The best number to reach you.
Who Needs the Certificate?*
Please separate names with a comma or semi colon.
What is Their Address?*
The address of the person or entity that's asking for a certificate.
Street Address
Address Line 2
State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMaryland MassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew Mexicoew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
City
Zip Code
What is Their Email?
Which of Your Policies Do They Need a Certificate For?* General LiabilityWorkers CompAutoUmbrella / Excess
Do They Need to be Named as an Additional Insured?*
Referring to the person or entity requiring the certificate.
NoYes
For Which Policies?*
Check all that apply.
General LiabilityAuto
Is There a Separate Certificate Holder?
Sometimes a separate entity, other than the additional insured, needs to receive a certificate of insurance as well.
YesNo
What is their name and address?
Name:
Address:
Waiver of Subrogation Required? YesNo
Primary and/or Non-Contributory Wording Required? YesNo
Are There Any Special Wording or Form Requirements?
For example, do they require a "CG 2010 11 85," or "Completed Operations Coverage"?
Please describe the special wording and/or form type
Is this Certificate Needed for a Construction, Janitorial, or Landscaping Project? *
Any job or project having to do with new construction, remodeling, or repair, service, or maintenance of a building, landscape, or structure.
Please describe the project *
What type of work are you doing (plumbing, electrical, etc.) ?
What type of service?
New ConstructionRemodelRepair/Service
What type of building?
CommercialResidential
Estimated gross revenue to be earned?
Any Additional Comments?
Send Us Some Helpful Documentation
For example, a copy of the request for a certificate, your contract, or a sample certificate.
Gillespie Insurance Services helps people and businesses in California, Arizona and Nevada.
