FORMS

Auto Insurance

Life Insurance

Health Insurance

Business Insurance

Homeowner's Insurance

Professional Liability

Financial Services

Certificate Request

Insured

Individual

Policy Number Please indicate policy number

Certificates Required

Workers Comp Please indicate if you require workers comp certificate or not

General Insurance (General Liability / Auto) Please indicate if you requiregeneral insurance certificate or not

NY Disability Please indicate if you require NY Disability certificate or not

Certificate Holder Please indicate certificate holder

Job Location Please indicate job location

Number of Days Cancellation Required (If Other than 5 Days) Please indicate the number of days cancellation required

Addtional Information or Instructions Please describe any addtional information or instructions

Is There a Copy of the Insurance Requirements Attached? Please indicate if a copy of the insurance requirements is attached

Please Send the Certificates in this Manner (Check One) Please indicate the way certificates are requested to be sent

The Certificate Needs to be Faxed? Please indicate if thecertificate needs to be faxed

1. Fax to: Please indicate the number to fax to

2. Fax to: Please indicate the number to fax to

General Liability Additional Insured Please note, when requiring an additional insured, all the information below is required

Contractors

Job Location(s) Please indicate job location(s)

Description of Job(s) Please describe job(s)

Cost of Job(s) Please indicate cost of job(s)

Expected Job Start and End Dates Please indicate expected job start and end dates

Additional Insured(s) and Relationships Please indicate additional insured(s) and relationships

All Other

Additional Insured(s) and Relationships Please indicate additional insured(s) and relationships

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Serving the following towns of the Northshore and Southshore of Long Island:

Nassau County -Baldwin, Garden City, Levittown, Valley Stream, Manhasset, New Hyde Park, Port Washington, Cold Spring Harbor, Glen Cove, Great Neck, Lloyd Harbor, Muttontown, Hicksville, Oyster Bay, Old Brookville, Roslyn, Massapequa, Wantagh, Bethpage, Seaford, Syosset, Woodbury and the surrounding areas.

Suffolk County - Babylon, Lindenhurst, Bayshore, Bohemia, Hauppauge, Melville, Shirley, Mastic, West Islip, East Islip, Oakdale, Sayville, Bayport, Huntington, Northport, Stonybrook, Kings Point, Smithtown, Saint James, Port Jefferson, Setauket, Mount Sinai, Miller Place, Center Moriches, Selden, Holbrook, Ronkonkoma, Medford and the surrounding areas.

Also serving the Five Boroughs and Tri State Area.

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