Certificate of Liability Insurance Request

It is recommended that the insurance specifications and the indemnification language from the contract be provided for our review. If you do not provide this information, we cannot determine if proper coverage is in place.
Please be advised that issuance of Certificates of Insurance for Workers Compensation coverage written with a MA Workers Compensation Assigned Risk carrier can have up to a 48-hour response time.
Specifications/Contract Provided? *
Client Information

Certificate Holder Information
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Special Requirements (Answer the following questions if you have not provided a copy of the job specifications)
Additional Insured(s): (Note – If you have blanket Additional coverage, it applies only if it is required in a contract or agreement with you that is written and signed prior to the commencement of the work.)
Required for: *
Primary: *
Non-Contributory: *
Waiver of Subrogation:
Applies to: *
Other Coverage Requirements*