Thomas Fenner Woods Agency, Inc.

Project Certificate Request

This form is to be used for existing coverages only. This request does not add, extend, alter or bind any coverages not currently in place. If a valid fax number is not included, the original will be mailed to the Certificate Holder and a copy to the Insured. It is our intent to provide the Certificate within 24 hours of a request. If a certificate is needed immediately, please complete and fax the form and call to notify our office.

Be sure to enter the required fields shown in red so we can process your information efficiently.

Insured Information:

Name Insured
Other DBA Name
Contact
Contact's Phone
FAX
E-mail
Web Address

Certificate Information:

Certificate Holder

Contact Person

Mailing Address

Address (cont.)

City

State

Zip

Phone

FAX

Coverage Applicable

Builders Risk

Installation Floater

Owner Carries Coverage

Project Information:
(Projects must be reported on Monthly Reporting Forms if Applicable)

Project Name

Project Amount

Length of Project

Number of Months

Multiple Copies?

Enter number of copies needed.

Describe any special requirement, including exact Additional Insured wording.

	Fax Certificate	Insured
	Mail Certificate	Holder
		Both

Explain any other special instructions.