Contractors Insurance Specialists 866.941.3631 Request Certificates (PRINT VERSION)

*Contact Name:

*Email:

*Please Issue Certificate To:

Attention:

*Company Name:

*Address:

*City

*State

*Zip Code:

*Phone:

Fax:

*Job Name/Number:

*Description & Location:

Special Requirements:
(charges may apply)

	Additional Insured Endorsement
	Waiver of Subrogation
	Primary Wording
	Cross out "endeavor to" and "but failure to mail..." in cancellation section of ACORD form
	Certificate only

*Sending Instructions:

	FAX directly to certificate holder FAX #:

	FAX Certificate to us

click here to print

Your protection and security are our primary concern.

CONTRACTORS INSURANCE SPECIALISTS
PO Box 2880
Lake Havasu City, AZ 86405
Local: (928) 846-3224
Toll-Free: (866) 941-3631
Fax: (928) 466-9122
lana@thecontractorsinsurancespecialists.com