INSURED (how the policy is listed)

CONTACT (insured contact information - i.e. owner, facility manager, etc.)

Name: Home Phone:   Business Phone:   Cell Phone:   Email:

GENERAL INFORMATION

List Name, Address and Relationship of each ADDITIONAL INSURED: List Name, Address and Relationship of each CERTIFICATE HOLDER: Description of any equipment and it's use:

CONTRACTING RISKS

Complete description of work being performed: Total Job Cost: Direct payroll and the applicable classification/s for Job: Subcontracted classes and costs: Estimated length of job: Location of the Job: City State Zip

IMPORTANT: Please be advised our carriers will NOT consider any of the following coverages: - Blanket Additional Insured - Waiver of Subrogation - Modifications to wording on Certificate - Additional days of reporting cancellations You may also print and fax this form for processing to: 212.937.3923