Document Request
Please complete the form below. Note that no changes will take effect until we review your request and you receive a confirmation from us. This will usually occur during our normal business hours. Please note that fields with asterisks are required.
For assistance, please see
instructions
.
I. Please identify yourself
Your name*
Insured*
Insured shown
on certificate*
Phone*
Cell
Fax
Email*
II. Security Code
If this is your first time using our on-line system, please enter a
security code of your choice, and we will contact you for verification.
Security Code*
III. Type of Request
Type of Request*
Please specify
Certificate of insurance
Evidence of property
Both certificate and property
Binder
IV. Document holder (To whom document is being given)
Name to appear*
Address*
City*
State*
Zip Code
-
Phone*
Fax
Email
Check all that apply
Additional insured
Mortgagee
Loss payee
If add'tl insured,
reason added
V. First additional interest
Name to apprear
Address
City
State
Zip Code
-
Phone
Fax
Email
Check all that apply
Additional insured
Mortgagee
Loss payee
If add'tl insured,
reason added
VI. Second additional interest
Name to apprear
Address
City
State
Zip Code
-
Phone
Fax
Email
Check all that apply
Additional insured
Mortgagee
Loss payee
If add'tl insured,
reason added
VII. Third additional interest
Name to apprear
Address
City
State
Zip Code
-
Phone
Fax
Email
Check all that apply
Additional insured
Mortgagee
Loss payee
If add'tl insured,
reason added
VIII. Indicate specific property this applies to
Vehicle
Equipment
Property location
Job
Other
IX. Policies to be shown
Policies to be
shown
General Liability
Automobile
Umbrella
Workers Compensation
Property
X. Document Deliveries
Deliver to*
Please specify
Insured
Certificate holder
Mortgagee or Loss payee
Deliver by*
Please specify
Mail
Fax
Email
XI. Special Instructions
© 2009 The Cohen Putnam Agency, Ltd.
Tel:
845-225-4100
Email:
lcohen@cohen-putnam.com
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