CERTIFICATE REQUEST FORM

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Bolds Insurance Brokerage

1447 Fourth Street

San Rafael, CA  94901

Phone: (415) 485-1700  Fax: (415) 485-1866

License #0D35007

 

INSURED INFORMATION
 
CERTIFICATE HOLDER INFORMATION

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REFERENCE (specific location, project, automobile etc)
 
CONTRACT PRICE (required for additional insured - contractors)
 
COVERAGE TO BE SHOWN ON CERTIFICATE
GENERAL LIABILITY yes   no
AUTOMOBILE LIABILITY yes   no
WORKERS COMPENSATION yes   no
UMBRELLA/EXCESS LIABILITY yes   no
   
SPECIAL REQUIREMENTS (must be approved by insurance company)
ADDITIONAL INSURED (x) yes   no
PRIMARY WORDING (x) yes   no
WAIVER OF SUBROGATION (x) yes   no
PER JOBSITE AGGREGATE (x) yes   no
OTHER REQUIREMENTS (describe below) (x)

(x) provide copy of lease, contract or agreement
 
COMMENTS
 
Only coverage arranged through Bolds Insurance Brokerage can be included on the certificate.
Certificates of Insurance can only be requested by the Named Insured