Pacific Benefit Consultants, Inc. -- Certificate of Insurance Request Form

This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

Insured Information

Insured Making Request: Date:

Address:

City: State: Zip:

Phone: Fax:

Email Address:

Recipient Information

Please issue Certificate of Insurance to the following:

Name:

Address:

City: State: Zip:

Attention:

Job Description: Job Name:
Cost of Job:
Duration of Job:

Do you want Certificate faxed?: Yes No Fax #:

Certificate Information

Policies to Reference*:

Auto
Umbrella General Liability
Equipment Workers' Comp.
Builders Risk

*Unless you specify differently, Auto, General Liability and Workers' Comp
will be the only policies indicated on Certificate (when applicable)

Additional Insured: Yes No If YES, Specify which policies and give details below:

Special Instructions

Please give any special instructions you feel appropriate for this certificate.

Select an Agent for Delivery

Please select an agent/representative below for delivery of this request:

(* REQUIRED)

Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.

This Certificate of Insurance Request Form Copyright © 1999 - by ENHANCED Web Services

Pacific Benefit Consultants, Inc.
450 Country Club Rd. Suite 330
Eugene, Oregon 97401
(541) 484-6624
(541) 686-2726 (Fax)
(800) 588-8688 (Toll Free)

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