Certificate of Insurance Heritage Insurance Brokers, LLC 15255 S 94th Ave, Ste 500 Orland Park, IL 60462 Phone: 708-263-6362 Fax: 708-260-9844 support@heritagecoverage.com REQUEST FOR CERTIFICATE OF INSURANCE Submitted by Date Named Insured Company/Policy # Certificate Holder – Name & Address Is an Additional Insured Endorsement to this policy required? YesNo If Yes, please provide the following: [Please note: an additional premium may apply.] Additional Insured – Name & Address Relationship to Insured If Additional Insured is job related, complete the following: Type of Work Being Done Start/Finish Dates Or Ongoing Job Estimated Cost of Job $ Exact Location of Job Remarks: (Please include any special contractual requirements such as waiver of subrogation and/or primary/non-contributory wording) Approved by Date
