Contractor Insurance

ADDITIONAL INSURED CERTIFICATE REQUEST

Note: This is only for existing clients' of Athena Insurance and Financial Services at www.ContractorInsurance.net. Please confirm your request by calling 209-223-1870 just incase your e-mail is not received.

Your request will be reviewed and processed within 24 to 48 hours if eligible. If you would like to upload the "Insurance requirement " part of your Proposed contract for Agent / Broker review please e-mail to steve@athenainsurance.com and in the subject line include the following; Additional Insured request plus the " project name" (SKIP YOUR MAIL, FAX, PHONE AND EMAIL UNLESS IT HAS CHANGED RECENTLY)

Todays Date

Need by date exp.

e-mail

Requestors Name

Business Name

Our Client: Mail address

Phone

Other Phone

Our Client: Fax

Preferred method of receipt

To Which policies?

General Liability	Professional Liability	Business Auto
Workers Comp.	Farm Liability	Trucking

First -ADDITIONAL INSURED INFORMATION

AI- Contact Name

AI - Business Name

AI - Mail address

AI - e-mail

AI - Phone

AI - Fax

Next -ADDITIONAL INSURED INFORMATION

AI- Contact Name

AI - Business Name

AI - Mail addresS

AI - e-mail

AI - Phone

AI - Fax

CHOOSE WHICH TYPE OF ENTITY IS REQUIRING TO BE NAMED ADDITIONAL INSURED ON YOUR POLICIY

Choose type of Requestor

Is this Cert. Job specific?

If "yes" please complet the section below

Job Number

Job Name and Location:

Estimated Start date

Estimated end date

DOES THE REQUESTOR REQUIRE SPECIAL ENDORSEMENT?

Is Waiver of Subrogation required?

Is Primary Wording required?

Enter Security Code:

FUTURE

STEVE VALENCIA

ATHENA INSURANCE AND FINANCIAL SERVICES 209-223-1870.

ADDITIONAL INSURED CERTIFICATE OF INSURANCE REQUEST FORM