Tegner Miller Client Services

Your name

Name and address of company requesting the certificate:

Company Name

Mailing Address

Street

City

State

Zip

Job Description or Location

Is the Company your:

If other please specify:

Is this a RUSH Certificate? Yes No

Receiver’s Name

Fax Number

Does the Company require an ADDITIONAL INSURED clause?
Yes No

Does the Company require a LOSS PAYABLE clause?
Yes No

Are there any special conditions or clauses which must be included (i.e. primary wording, waiver of subrogation, etc.). If so, please describe the exact request: