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