1. Contact Information:

A copy of the certificate will be sent to the email above.

2. Issue the Certificate To:

3. Certificate Delivery:

To complete your request you may do one of the following:

1. If items 1-3 above contain all the information needed, click Submit Certificate Request at the bottom of this form.
2. If the certificate requires a more detailed specification:

Either:

Send us the Insurance Requirements section of the project contract by fax or by attaching below and we will issue a certification as per the contract’s requirements.

Fax #: 1-360-598-3703 - Attn: Certificate Department
If faxing requirements, click Submit Certificate Request at the bottom of this form.

Attach the Insurance Requirements section only here:
(max. file size is 5 MB)

Once file is attached, submit the certificate request at the bottom of this form. [clear attachment]

Or:

Complete the Certificate Specification (questions 4 – 7 below) and click Submit Certificate Request at the bottom of this form.

Certificate Specification

4. Do you have a written contract requiring you to name the Certificate Holder as Additional Insured? Yes No

If Yes, Please Specify which Coverages are to be Included:
General Liability Automobile Liability

Further, does your contract require that we attach a special Additional Insured Endorsement?
Yes No

Please list all Additional Insureds Names/ Entities that need to be included on the Certificate:

1.
2.
3.
4.

Please Note: Naming a Certificate Holder as Additional Insured on a Professional Liability Insurance Policy is not available or allowable.

5. Does the written contract require a Waiver of Subrogation?

Yes No

If yes, let us know what the Waiver of Subrogation is for (Check all that Apply):
General Liability
Workers Compensation
Automobile Liability
Excess/Umbrella

Does the written contract require a Waiver of Subrogation Endorsement to be attached to the certificate?
Yes No

6. Does the written contract require that the Certificate Holder be Named with Primary and Non-Contributory Additional Insured Language?

Yes No

If Yes, is an Additional Insured Primary Endorsement Required?
Yes No

7. Does the written contract require the following Language to be deleted as Specified in Your Contract? "Delete the wording 'endeavor to' and 'but failure to mail.' from cancellation clause"?

Yes No