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Request a General Liability Certificate of Insurance with Additional Insured


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Insured Information
First Name
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Last Name
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Company Name
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Primary Phone Number
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E-Mail Address
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Certificate Holder
Company Name
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Street
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City
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State
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ZIP / Postal Code
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Additional Insured Information
Do you have a written contract?
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Start Date of Job
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/ /
Specific Location of Job
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Cost of Job
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Specific Operations Involved in Job
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Any Hazardous Duties? (If yes, please describe
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How much control does the additional insured have over our insured's employees?
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How much control does our insured have over the jobsite?
Required
Special wording required by contract:
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Delivery Method
How should we Deliver the Certificate
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E-Mail Address
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Fax #
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Mailing Address
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Mailing Address Line 2
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Gerelli Insurance Agency, Inc.   |   PO Box 362, Cold Spring, NY 10516   |   (845) 265-2220   |  Fax: (845) 265-4754               Powered by Insurance Website Builder 

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