Contractor Certificate of Insurance Request Date Requested By: Name From (Business Name) Email Address Telephone Number Please Select Please Select Auto Workers Comp General Liability Umbrella Other Other - Describe: Describe the contract requirements of written contracts - Project Description Additional Insureds by Line of Business Additional Insureds by Line of Business Auto Workers Comp General Liability Umbrella Other Other Additional Insureds Additional Insureds Waiver of Subrogation Waiver of Subrogation Auto Workers Comp General Liability Umbrella Other Waiver of Subrogation Prepare a Certificate of Insurance to the following: Name on Certificate Address Address Line 2 City State Zip Code Email (or Fax) Send Certificate to (if different from above): Please send me a copy of the Certificate: Please send me a copy of the Certificate: No Yes 7 + 4 = Submit Serving Cape Cod, the Islands and South Shore since 1990.
