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 recive 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.

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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.

Community Insurance Group

139 Harristown Road, Suite 202
Glen Rock, New Jersey 07452

Phone:
Toll Free:
Fax:
Fax (NJ only):

201-444-4426
855-344-4426
201-444-0731
800-440-2267