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

Get Adobe Flash player
AJ Benet Home Page About AJ Benet Insurance Personal Insurance from AJ Benet Business Insurance from AJ Benet Testimonials from Clients of AJ Benet Insurance Services for Clients of AJ Benet Insurance Insurance company partners with AJ Benet independent insurance brokers Contact the Professional Staff at AJ Benet Insurance


For a no-obligation consultation on homeowners, automobile, life, yacht, business, or group health insurance,
call 914-381-2040
and speak with
an experienced
A.J. Benet professional or email info@AJBenet.com

A.J.Benet Home Page > Client Services > Certificate of Insurance

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.
 

PLEASE NOTE: If you have a printed copy of the Request For A Certificate, please fax it to (914)381-5089.

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 Reference:

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:

Waiver of Subrogation:

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

30 days Notice of Cancellation:

Yes No


Special Instructions

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


PLEASE NOTE: If you have a printed copy of the Request For A Certificate, please fax it to (914)381-5089.

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.

   

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

Home | About Us | Personal Insurance | Business Insurance | Testimonials | Client Services | Insurance Partners | Staff Contacts | Site Map

A. J. Benet, Inc. • 430 Center Avenue • Mamaroneck, NY 10543 • Customer Service: 914-381-2040 • Sales: 914-381-0177 • Fax: 914-381-5089

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states.
For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

©2012 A.J. Benet, Inc. Insurance