Cafarelli Insurance Agency Ltd
Tel: 631.543.6363 Fax:631.543.4891
1030 Jericho Tpke. Smithtown, NY 11787
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Cafarelli Realty
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Automobile Application
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Auto Insurance
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Insured
Individual
Policy Number
Certificates Required
Workers Comp
Yes
No
General Insurance (General Liability / Auto)
Yes
No
NY Disability
Yes
No
Certificate Holder
Job Location
Number of Days Cancellation Required (If Other than 5 Days)
Addtional Information or Instructions
Is There a Copy of the Insurance Requirements Attached?
Yes
No
Please Send the Certificates in this Manner (Check One)
Mail All Copies to the Insured
Mail One Copy to the Insured and One to the Certificate Holder
The Certificate Needs to be Faxed?
Yes
No
1. Fax to:
2. Fax to:
General Liability Additional Insured
Contractors
Job Location(s)
Description of Job(s)
Cost of Job(s)
Expected Job Start and End Dates
Additional Insured(s) and Relationships
All Other
Additional Insured(s) and Relationships
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