Certificate of Insurance Request Form
Fill out the Certificate of Insurance Request Form and click Send.
Certificate Holder & Address - Address must be completely filled in.
(Client or customer asking for the cert)
Certificate Holder's Name
Address 1
Address 2
City
State
Zip
Phone

Description Section
Operations/Locations/Vehicles/Special Items/Contract.
Lease or Job Number/Leased Premises/Special wording or conditions.

Requestor (CLARCOR employee) - Address must be completely filled in.
Requestor's Name
Email Address
CLARCOR Company Name
Address
City
State
Zip
Phone
Certificate Holder's Interest
Additional Insured
Loss Payee
[All-Risk Property Policy only;
e.g. leased equipment and crime]
Lines of Coverage to be Evidenced
General Liability $2,000,000
Automotive Liability $2,000,000
Workers Compensation/Employers' Liability $1,000,000
Commercial Crime
[Also known as Fidelity Bond]
$1,000,000
All-Risk Property Replacement Cost Coverage (no limits)
Excess/Umbrella $6,000,000
Professional Liability (SPS only) $2,000,000
If different limits are required from what is listed above, please specify here and for which insurance policy:
Email Certificate To
Email Address(es)
Fax Copy Requested
No
Yes
Recipient's Name
Fax
Notes:

Unless you request a certificate holder (customer, landlord, etc.) be removed from the database, they will receive every year, automatically, a renewal certificate of insurance via regular U.S. Postal Service mail.

This form is for brand new requests only. For changes to existing certificates of insurance, please email the changes needed to Hailey Aldren at haldren@clarcor.com.
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