Workers’ Compensation Certificate Request

 

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 #