Certificate Of Insurance

Should this certificate be issued annually?  Yes No

Description of Property: Location of Property:
Address: City: State: Select a State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code: Reference Number: Does Loss Payee also need to be added as additional insured? Yes No

Property Address (including apt/unit number Address): City: State: Select a State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code: Loan Number: Does Mortgagee also need to be added as additional insured? Yes No

The Certificate Holder has requested to be named as an additional insured on the policy for liability purposes.(Adding an additional insured to your policy may change your premium.)

The Additional Insured is a Landlord or Manager of the premises. The Additional Insured is in relation to a Project/Contract. The Additional Insured is in relation to a Vehicle. Other/Additional Information? The Additional Insured relation is not listed above. Is there any special wording required on your certificate by the certificate holder? (Special Wording is subject to Underwriter review.)  What is the effective date of this change? Should this certificate be issued annually? Yes No