CERTIFICATE OF INSURANCE REQUEST Date MM slash DD slash YYYY please format as: mm/dd/yyyyPlease select Auto Workers Comp General Liability Umbrella Other Please check those that apply Written Contract No Written Contract Current Policy Term Prior Term By (Requested)* From (Business Name)* Email* Phone*Prepare a Certificate of Insurance to the followingName Address Special Conditions Additional Insured (if required) Provide Project Specifications, Contractual Insurance Requirements and Example Certificates if available. Return to: Please enter email, fax number or mailing address of recipientPlease send me a copy of the Certificate: No Yes Certificate will be mailed, faxed or emailed per your request.NOTE: Certificates for Workers Compensation policies written through the MA Workers Compensation Risk Plan must be issued directly by the insurance company wiriting the policy. RogersGray will order the certificate which will be issed by the carrier within two (2) business days. A copy will be kept on file for the insured unless instructed otherwise. Certificate will be available within 24 hours.
