H & H Insurance | Certificate of Insurance Request

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		H & H Insurance Services 3160 Campus Drive, Suite 100 Norcross, GA 30071 Telephone (770) 409-0014 Facsimile (770) 368-0404
	H & H Insurance can assist you with all of your bond and insurance needs. Please contact us today!

Certificate
of Insurance
Request Form This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information as possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

Insured Information
Insured Making Request:	Date:
Address:
City:	State: Zip:
Phone:	Fax:
Email Address:

Recipient Information

Please issue Certificate of Insurance to the following:

Name:

Address:

City: State: Zip:

Attention:

Job Reference:

Do you want Certificate faxed?: Yes No Fax #:

Certificate Information

Policies to Reference*:

Auto
Umbrella       General Liability   Equipment Workers' Comp.   Builders Risk

*Unless you specify differently, Auto, General Liability and Workers' Comp will be
the only policies indicated on Certificate (when applicable)

Additional Insured: Yes No   If YES, Specify which policies and give details below:

Waiver of Subrogation: Yes No   If YES, Specify which policies and give details below:

30 days Notice of Cancellation: Yes No

Special Instructions

Please give any special instructions you feel appropriate for this certificate.

Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.

H & H Insurance
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Certificate of Insurance Request Form		This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information as possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

Recipient Information
Please issue Certificate of Insurance to the following:
Name:
Address:
City:	State: Zip:
Attention:
Job Reference:
Do you want Certificate faxed?:	Yes No Fax #: