The McIntyre Group

Forms

Online Application

Please complete this form to submit a request for a Certificate of Insurance . It is important to include as much information as possible to receive an accurate certificate. Upon receipt, we will review your request, contact you if additional information is required, and then we will send the certificate of insurance to the appropriate party or parties. This information will be kept strictly confidential and will be used for these purposes only.

* Required Fields

Insured Information
*Insured Name:
*Submitted By:
*Email:

Certificate Holder Information
*Name:
*Address:
*City:
*State:
*Zip:
*Phone:
Fax:
*Email:

Job Name/Job Description/ Job or Project Number
(Only if applicable. If a blanket certificate is preferred please advise)

Dose the Certificate Holder need to be named as Additional Insured?

 Yes No

If yes, please provide all entities to be named as Additional Insureds

Does the Certificate Holder need to be named as Loss Payee?

 Yes No

If yes, please provide all entities to be named as Additional Insureds:

Special Instructions:

Included Insurance Provision from Contract and/or any Insurance related documentation:

(File formats: DOC, DOCX, PDF)