Certificate Request Form

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"ENTER" KEY WILL SUBMIT INSTANTLY.   Use "TAB" key or MOUSE to scroll through then Click "Submit"
Questions / Problems, call: (412) 271-8888

 Account / Business Name
  (Your Account Information)
 City, State
 Person completing this form Email or Phone:

CERTIFICATE HOLDER INFORMATION
 
- Below is not for your business's info.  Enter information for the entity which is requesting a certificate -
( All information is required )

 Entity Name
 Entity Name (add'l space)
 Address
 Address (add'l space)
 City, State, Zip
 Reason for Certificate  Permit or License Grantor     Vendor (sells your services)
 * Use of Land     * Landlord, or Manager of Premises

 *  If "Use of Land" or "Landlord / Mgr Prem's", please list the full address of the space / plot of land, or an area description if no address is available for the land this pertains to:
 

         

 --------------- IF NONE OF THE ABOVE, complete below ------------------
   Explain the relationship between your company and the requesting entity?  What services are being provided between your company and the requesting entity?  

 Dates of the job, service(s), trip(s) - If Applicable ?
 Is there a written contract between you and the requesting entity?  Yes      No
 Is Certificate Holder to be named as an Additional Insured?  Yes      No
Do not check "Yes" if you are not sure.  Adding an entity as an Additional Insured (checking "Yes") may result in a premium charge to you, as this will extend liability coverage (defense costs & possible payment of a claim) to that entity.
 Applicable Lines of Insurance? Check all which apply, only if known. General Liability     Auto Liability     Umbrella   
Employers Liability (Work Comp)     Professional Liability (E&O)
Other (ie Bond, etc. Use Add'l Comments below to define if necessary.)

PROCESSING INSTRUCTIONS

 Send to Certificate Holder by?  Email....Address?
                                                  
Fax #?
 Do you need a copy?   If yes, by:   Email....Address?
                                                       
Fax #?

Additional Comments / Information


PLACE INITIALS HERE TO VALIDATE FORM  

NOTE: Some entity's have unique wording / coverage in their requirements.  If you are not sure that your
insurance coverage is adequate, please forward a copy of the insurance requirements to us for review:
Email Copy to:  insurance@thompsongusic.com    or    Fax Copy to: (877) 271-8898
Questions: (412) 271-8888

Otherwise, "Submit" below


 

T.R.G.
Copyright 2000 [Thompson-Gusic Insurance Group, Inc.].  ALL RIGHTS RESERVED
Revised: June 20, 2017 .