R. H. Nicholson & Company, Inc.: Certificate of Insurance Request Form

Licensed in:
Virginia, Maryland, Washington D.C.

Certificate of Insurance Request Form

This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

Insured Information
Insured Making Request:	Date:
Address:
City:	State: Zip:
Phone:	Fax:
Email Address:

Recipient Information

Please issue Certificate of Insurance to the following:

Name:

Address:

City: State: Zip:

Attention:

Job Reference:

Do you want Certificate faxed?: Yes No Fax #:

Certificate Information

Policies to
Reference*:

Auto
Umbrella General Liability
Equipment Workers' Comp.
Builders Risk

*Unless you specify differently, Auto, General Liability and
Workers' Comp will be the only policies indicated on
Certificate (when applicable)

Additional Insured: Yes No If YES,
Specify which policies and give details below:

Waiver of Subrogation: Yes No If YES,
Specify which policies and give details below:

30 days Notice of Cancellation: Yes No

Special Instructions

Please give any special instructions you feel
appropriate for this certificate.

Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.



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