CERTIFICATE & ADDITIONAL INSURED REQUEST FORM

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CERTIFICATE & ADDITIONAL INSURED REQUEST form To: H. R. Keller & Co., Inc. CERTIFICATE Issuance From:___________________________ INSURED s Name:___________________________________ ______________________________ Policy No. ___________________or Quote #_______________ Date: ________________ COMPLETE THIS form FOR EACH CERTIFICATE HOLDER OR ADDITIONAL INSURED BEING REQUESTED. Return by e-mail to: or Fax: (716) 874-4920 WE CANNOT TAKE REQUESTS BY PHONE. PLEASE BE SURE TO MARK THE APPROPRIATE BOX. CERTIFICATE Holder Only ADDITIONAL INSURED (no Charge) ( ADDITIONAL FULLY EARNED charges apply A BLANKET ADDITIONAL INSURED ENDORSEMENT APPLIES TO THIS POLICY. MULTIPLE A/I S PERTAINING TO THE SAME JOB (ATTACH SEPARATE SHEET FOR EACH A/I) PLEASE INCLUDE THE ATTACHED 1 A/I (S) ON ONE CERT. CERTIFICATE HOLDER/ ADD. INSD. NAME:___________________________________ ___________________________ ADDRESS:________________________________ ________________________________________ __________________ (Please include Apt.))

CERTIFICATE & ADDITIONAL INSURED REQUEST FORM To: H. R. Keller & Co., Inc. Certificate Issuance From:_____ Insured’s Name:_____

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