Clark & Morrison Insurance Agency, Inc.

Firm Name
Contact Name:
Email Address:
Phone Number:
Certificate Holder Information (Complete address required even if faxing)
Name:
Address:
City:		State:	Zip
Contact Name:
Job Reference:
Certificate Holder as an Additional Insured: Yes No
(NOTE: Remember that by adding an Additional Insured, you are agreeing to share your insurance limits with this person or company should you both be sued. The company has a right to charge an additional premium for adding an additional insured.)
Fax? Yes No	Fax Number:
30 Days Notice of Cancellation?: Yes No
Do any other Additional Insureds need to be listed?: Yes No
(If yes, specify below their name, address and relationship to the job:

Any Special Wording or Additional Information?: Yes No
(NOTE: Copy of Insurance Agreement and/or contract should be provided)