REQUEST FOR CERTIFICATE OF INSURANCE
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REQUEST FOR CERTIFICATE OF INSURANCE
(THIS FORM IS PROVIDED FOR THE CUSTOMER TO APPROVE AND FORWARD TO THEIR INSURERS)
DATE: ________________________________
TO: CUSTOMER’S INSURANCE AGENT DESCRIPTION OF ITEM(S) TO BE INSURED
NAME OF AGENCY __________________________________________________ _____________________________ _____________
ADDRESS ___________________________________________________________ ___________________________________________
_______________________________________________ __________________________________
PHONE _____________________________________________________________ ___________________________________________
FAX _______________________________________________________________ ___________________________________________
AGENT _____________________________________________________________ INSURABLE VALUE _________________________
We have entered into an agreement with the Owner for the above described item(s). This is a “NET” agreement and we are responsible for the insurance. The insurance policy must include a provision for the following requirements:
1. COMPREHENSIVE GENERAL LIABILITY/PROPERTY DAMAGE COVERAGE:
2. Loss Payee clause information (can not name Certificate Holder as Loss Payee, we need to be named specifically as loss payee):
LEASING SERVICES
c/o ABIC – Lease Insurance Services- 5th Floor
PO Box 979280
Miami, FL 33197-9280
3. Special Form Coverage, All Risk including theft
4. Effective and Expiration of Coverage
I authorize the above agent to immediately place the insurance coverage required for the described item(s). Please issue a binder of insurance to the above named additional Insured and Loss Payee by return mail and replace it with the original insurance policy endorsement within 30 days.
This Certificate should indicate the following: “It is agreed that Leasing Services will be notified in writing 10 days prior to cancellation of other material change in the conditions of this policy”.
IMPORTANT: Insurance agent please send completed Insurance Certificate by fax: 1-305-259-4577 or e-mail GAmail@. You can also mail to the loss payee above.
CUSTOMER: _____________________________________________________
(FULL LEGAL NAME)
STREET: _________________________________________________________
CITY,STATE & ZIP: _______________________________________________
SIGNATURE: _____________________________________________________
TITLE: ___________________________________________________________
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