Untitled Document

Content on this page requires a newer version of Adobe Flash Player.

Get Adobe Flash player


Pay
On-line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certificate Order Form

This form is for the use of Hudson & Muma customers. Please fill-in this form to reqeuste a Certificate of Insurance on our commercial or personal insurance. Remember, without complete information, we may be delayed in producing your certificate, so please complete ALL applicable fields.
"*" indicates required fields.

 

CERTIFICATE NEEDED NO LATER THAN: (date)

Insured Information
PLEASE ENTER YOUR NAME* :
Company Name*:
Phone Number:
Fax Number:
Email Address:
Type of Form Needed

COMMERCIAL CERTIFICATE OR EVIDENCE OF PROPERTY
(Certificate Holder refers to the name of the person/entity requesting proof of coverage)

Certificate Holder Name: *
Attention:
Cert. Holder Address:
Cert. Holder Address 2:
Cert. Holder City/ST/Zip
Cert. Holder Phone #:
Cert. Holder Fax #:
Cert. Holder E-Mail:
Delivery Method:

CERTIFICATE DESCRIPTION:
(i.e., description of operation for which you need certificate.
If the holder has requested a specific verbiage fo rthe certificate please put here as well.)
(e.g. For Contracted Work of Insured at Certificate Holder location at 1234 Main St., Any town MI 48888)

 

Certificate Holder, Nature of Interest
Of the following, check ALL that apply:
(Check all that apply)
NO Interest Just Needs to See Coverage
Additional Insured
Loss Payee
Lender Loss Payee
Additional Insured/Loss Payee
Additional Insured/Lender Loss Payee
Mortgagee
Lessor (Specify what is being leased and
......it's value in "NOTES" below)
Hold Harmless
Leinholder		 Lines of Business to Include
Choose ALL that apply:
(Check all that apply)
**..ALL LINES..**
Commercial General Liability
Commercial Automobile
Workers Compensation
Umbrella Liability
Property - Real (specify address in
...... NOTES" below)
Property - Contents
Property - Equipment (specify
...... equipment in "NOTES" below)
Professional Liability
Personal - Home Owners

Notes:

ATTACHMENTS:

If you have a sample from the Certificate Holder or certain portions of a
contract that specify what is needed, please attach here.

Attachment 1:
Attachment 2:
Attachment 3:

Name of person completing form:

Confirmation Email Address*:
(We need this to send you a confirmation receipt for this form. See our Privacy Policy HERE)


Adobe Versions
(for printing and faxing back to us):

CLICK HERE

Get Adobe Reader
(need Acrobat Reader to view? Click the icon)

©2003-2009 Hudson & Muma, Inc.

 

insure-all.com 

FILM PRODUCER & OTHER PROGRAMS:
GUIDE LINES FOR ORDERING CERTIFICATES

 In order to speed up the process of ordering and receiving
certificates, we ask that the following guide lines be used:

General Information for all Certificates:

  1.  Name

  2. Address

  3. Phone

  4. Fax

  5. E-Mail Address (if available)

  6. Does the certificate holder want to be named as an additional insured?

  7. Does the certificate holder require any special wording on the certificate?

(If  requirements are in writing please send us a copy) 

Additional Information needed for
Rentals of Equipment

1)      Need a list of equipment with the following information:

  1. Make:

  2. Model:

  3. Serial Number:

  4. Value:

2)      If a vehicle is the rental item we need the value of same.

3)      The dates you are renting the equipment.

Please order certificates well in advance (24 hours) this will
prevent any delays in issuing them due to unforeseen problems.

Note: As a general rule e-mails arrive faster than faxes. 

 

 

 

insure-all.com

insure-all.com


Copyright © 1997-2012 Hudson & Muma, Inc.
PLEASE READ TERMS OF USE and PRIVACY POLICY
Address all inquiries to webmaster@hudsonmuma.com
GLOSSARY OF INSURANCE TERMS