(changes will be effective upon confirmation by a King & Neel representative)

Please use your TAB key to move through the form...

(* means required)
 

* Your Business Name

 

* Your Name

* Phone

* Email Address

Fax Number

 * Effective Date of the Change

   

 

Description of the Certificate Holder:

* Certificate Holder Name

 

* Street Address

 

Street Address #2

 

* City

 

State

 

Zip

 

 

     
               Certificate Holder is to be named as: Additional Insured

(if required by written contract)

Loss Payee
  Mortgagee

 

Additional Insureds

(other than the Cert Holder)

 

Will fax copy of insurance requirement section of the contract (if applicable)

 

Show the following coverages on the certificate:

 

General Liability

Property
 

Automobile

Umbrella
 

Workers Compensation

Other: 

 

Purpose of the Certificate: 

   

Specify, if Other:

 
                     Contract No. (if applicable)



Description of Job, Location or Reason for the Certificate
Is this an Owner Controlled (OCIP) Project?    Yes


OTHER COMMENTS OR REMARKS?

 

If you would like a copy, please PRINT before hitting "submit".  Thank you!