Website Certificate Request

 In the first section, please enter the name of your company followed by the box where you enter the email address of your company.

In the next section, you will provide the certificate holder information. Please enter the name of your client, followed by their email, phone number, address, city, state, and zipcode.

The next section is optional.

If you are requesting a waiver of subrogation - in the event that you want to ‘safeguard your business’ by obtaining these special endorsements to shield your company from liability on projects, you may fill this form out. 

First, click on the drop-down arrow and indicate your choice to pay the $200 fee. Secondly, enter the fax number where you want your waiver certificate sent.

Now, enter the stard date and the end date of the project if available.

Alternatively, you may enter the approximate length of the project. If the project is ongoing, please indicate in the box labeled ‘length of project’. Below this box is another box where you can input the ‘contract number’.

You will add the number of employees involved in this project followed by class code and exposure amount.

The following box will be the types of goods hauled. Then you will enter the location where the project will be carried out.

In the next box, you will provide the specific work description that is being affected by this exception or change. The next section will provide you an option to choose whether the exception/changes being requested or required.

Finally, If you have any additional instructions or requests, you may enter this in the last box. You may upload a sample of a certificate - which is recommended. You can also add any additional notes pertaining to project name, location and details - if applicable.

The next section is optional, should you decide to upload a sample certificate. In order to attach this document, click on ‘Upload a file’. This is where you will be able to access the file of choice from your computer or appropriate hard drive. Once you have selected the file to upload, click on the ‘open’ button on the box. This will upload the file you have chosen. 

Now that you have completed your form, please click on the box below acknowledging that all the information is true and correct, to the best of your knowledge.