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Form: Certificate of Insurance
Certificate of Insurance



Insured Information
Insured Name:
Policy Number:
Insured Phone Number:
Certificate Information
Name of Company or Certificate Holder:
Job Reference Number:
Certificate Holder Street Address:
City:
State: Zip:
Certificate Holder Email Address:
Certificate Holder Fax:
(include area code)
Requesters Information
Your Name:
Contact Email Address:
Handling Method:
(if other, please describe in comments area below)
Required Coverages
Please provide copy of insurance
requirements of contract:
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
Yes No
Need Endorsements for Primary Wording:
Yes No
Additional Insured:
Yes No
Loss Payee:
Yes No
Mortgagee:
Yes No
Comments or Other Instructions

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Gordon Insurance Associates, Inc.
20470 W. Lake Pleasant Road, Ste. 107
Peoria, Arizona 85382
Office: (623) 486-6815
Fax:     (888) 870-9690
Email: info@giasite.com

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