Niagara National Agencies - Insurance Sales and Service

CERTIFICATE OF INSURANCE REQUEST
Insured Name:
Insured Phone Number:
Certificate Holder Name: (Person the certificate will be going to)
Attention:
Address:
City:
State:
Zip:
Fax:
Email:
Are any special requirements/conditions required by the Certificate Holder such as to be named as Additional Insured? Yes No If yes, please fax a copy of the requirement/condition to: Attn.: Business Dept. 716-684-6285
Date and Time job will begin:
Description of Job:
Your relationship with the Certificate Holder:	I am the subcontractor. Other. Describe:
Do you have a WRITTEN CONTRACT with the Certificate Holder? Yes No