Lubin-Bergman Organization

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Request a Certificate

* Your Firm Name:

* Your Name:

* Certificate Holder:

* Attention:

* Address:

* City

* State

* Zip Code:

* Is the Certificate Holder requesting to be named as an additional insured on your General Liability coverage (if applicable)?

YES
NO

(Note that most policies require that this request be part of a written contract or agreement in order for the additional insured coverage to apply.)

If Yes, indicate who should be listed as an additional insured if other than the Certificate Holder:

* Please indicate which coverages should appear on the Certificate:

General Liability		Umbrella (Excess) Coverage
Automobile Liability		Professional Liability (E&O)
Workers' Compensation		All policies should be listed
Property Certificate
Minimum number of selections not met.

* Email/Fax
Certificate to:

Other Instructions: