BENTON INSURANCE AGENCY 800-864-2001

CERTIFICATE OF INSURANCE REQUEST

Certificate of Insurance Request
Disclaimer: Insurance transactions are NOT effective without acknowledgement
from a Benton Insurance Agency Representative.

*

Certificates issued in 24 hours or less! We will issue all Certificates of Insurance and Additional Insured endorsements that do not require insurance company approval in 24 hours or less. If you are a new client of Benton Insurance Agency, we will issue your Certificate within 24 hours of receiving the policy number.

*Your Company:

*Your Address

*Company Name / Certificate Holder:

*Address:

*City

*State

CA

*Zip Code:

Attention:

Phone:

Fax:

Job Name/Number:

*Job Description & Job Address:

*Certificate holder requires
certificate(s) showing coverage for:

	General Liability
	Automobile Liability
	Workers' compensation/ Employer's Liability
	Other:

Special Requirements:
(charges may apply)

	Additional Insured Endorsement
	Primary Wording
	Cross out "endeavor to" and "but failure to mail..." in cancellation section of ACORD form
	Waiver of Subrogation
	Other: