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DurAmerica Brokerage
214 W 39th Street, Suite 207
New York, NY 10018
Sales: 855-777-6932
Support: 212-302-2672

Copyright ©2018 DurAmerica. All Rights Are Reserved

Certificate of Insurance Request

Do you prefer a basic email upload submission?*
- No
- Yes
Name*
Email*
Enter Email Confirm Email
Subject*
Message*
Upload your files (maximum of 3)*
Drop files here or
Accepted file types: pdf.
Please tell us a bit about yourself
Name*
First Last
Company (if any)
Email*
Phone Number*
Fax Number
Insured/Policy Holder Information
Name/Company Name*
Policy Number
Email
Certificate Holder Information
Name/Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Additional Coverages and Specifics
Additional Coverages Requested
- Waiver of Subrogation
- Primary and Non-contributory Basis
- Per Project Aggregate
- Ongoing Operations (CG 2010 or its equivalent)
- Completed Operations (CG 2037 or its equivalent)
Job Dates
Begin
End
** CERTIFICATE REQUIRES ADDITIONAL INSURED TO HAVE A VALID WRITTEN CONTRACT IN PLACE AS DEFINED IN THE POLICY **
Job Description
Please attach certificate sample and/or requirements (5 maximum)
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Accepted file types: pdf.
Are there Additional Insureds*
- Yes
- No
Add Additional Insureds
Person or organization that enjoys the benefits of being insured under an insurance policy. List up to 5 insured people/companies
If you require more than 5 additional insureds, please use the basic method at the top of this form
Number of Additional Insureds*
Please provide the insurable interest of EACH entity
Additional #1
Name/Company Name*
Insurable Interest*
Additional #2
Name/Company Name*
Insurable Interest*
Additional #3
Name/Company Name*
Insurable Interest*
Additional #4
Name/Company Name*
Insurable Interest*
Additional #5
Name/Company Name*
Insurable Interest*
Name
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Products of Interest
Pick Your Industry*
Please choose products of interest*
- Bonds
- Builders Risk
- Commercial Auto
- Commercial Property
- Contractor’s Equipment Policy
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Pollution Liability
- Railroad Protective Liability
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- Hired & Non-Owned Auto
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Directors & Officers Insurance
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- Hired & Non-Owned Auto
- Professional Liability
- Workers Compesation
Please choose products of interest*
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Liquor Liability
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Workers Compesation
Please choose products of interest*
- Bonds
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Product Liability
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Directors & Officers Insurance
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- Hired & Non-Owned Auto
- Workers Compesation
Please choose products of interest*
- Bonds
- Builders Risk
- Business Owner’s Insurance (BOP)
- Cargo Insurance
- Commercial Auto
- Commercial Property
- Contractor’s Equipment Policy
- Cyber Liability
- Directors & Officers Insurance
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Liquor Liability
- Machinery Breakdown
- Pollution Liability
- Product Liability
- Professional Liability
- Railroad Protective Liability
- Wharehouseman’s Legal Liability
- Workers Compesation
Please choose products of interest*
- Commercial Auto
- Commercial Property
- Cyber Liability
- Directors & Officers Insurance
- Employment Practices Liability Insurance (EPLI)
- Errors and Omissions
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Machinery Breakdown
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Liquor Liability
- Workers Compesation
Please choose products of interest*
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- Hired & Non-Owned Auto
- Liquor Liability
- Product Liability
- Workers Compesation
Please choose products of interest*
- Cargo Insurance
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Railroad Protective Liability
- Wharehouseman’s Legal Liability
- Workers Compesation
Please choose products of interest*
- Bonds
- Business Owner’s Insurance (BOP)
- Commercial Auto
- Commercial Property
- Cyber Liability
- Employment Practices Liability Insurance (EPLI)
- Excess/Umbrella Liability
- General Liability Insurance
- Hired & Non-Owned Auto
- Liquor Liability
- Product Liability
- Railroad Protective Liability
- Wharehouseman’s Legal Liability
- Workers Compesation
Individual Information
Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Website
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Info
Company Name
Year Established
Number of Employees
Annual Revenue
Additional Info
Notes*
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Email
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