Request for Certificate

HarbisonWalker International Inc.
Request for Certificate

Please provide the following information for the company that will be receiving this Certificate of Insurance.

Date Requested: 4/20/2024

Date Needed:

Requested by:

Phone:

Fax:

Email:

Do you require a copy? No Yes

Fax Email

Request Details

Certificate Holder

Coverage

Limits

Company Name:

Attention:

Address:

Holder's Interest (to be shown on certificate)
Evidence Only	Additional Insured
Waiver of Subrogation	Loss Payee
Mortgage
Other (attach contract wording)
Check here if this certificate should be added to your permanent holder list?

General Liability

Automobile Liability

Workers' Comp.

Umbrella/Excess Liab.

$3,000,000 / $5,000,000

$2,000,000

$1,000,000

(Up to $25,000,000)

If Property Certificate Requested Include Detailed Description of Property, Location of Property, Value to be insured and Effective and Expiration Dates of Certificate.

Special Instructions:

Distribution

How should the certificate be sent?

Fax to:

Regular Mail
Mailing address if other than certificate holder address:

Email to:

Name:		Fax:
Name:		Fax:
Name:		Fax: