This Certificate of Insurance Request Form is for existing clients of AmCheck who hold commercial workers compensation 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. A copy of the certificate will be mailed to both the certificate holder and the named insured within one business day.

Workers Compensation Certificate

Insured Information

* Individual Making Request
* Company
* Address
* City
* State
* ZIP
* Phone
Fax #
* Email Address

Recipient Information

Please issue Certificate of Insurance to the following:

* Name
* Address
* City
* State
* Zip
* Attention

If Project specific, please fill in job information below, otherwise put N/a:

* Job Reference
* Description of Work
* Project Owner’s Name
* Location of Project/Job
* State
* Contract, Project or Job #

Certificate Information

* Other information or
requirements

Certificate Distribution Information

If not filled out, certificates will be mailed first class through US Postal Service Insured.

* Email Address
FAX #

Certificate Holder

* Email Address
Fax #



Workers Compensation Certificate Request