Insurance: Best Rates for Construction/Contractor, Transportation/Trucking, Auto Parts/Service Businesses through Powers&Company.

Certificate of Insurance
Disclaimer: Insurance transactions are NOT effective without acknowledgement from a Powers & Company Representative.

Certificate Hotline™ - Certificates issued in 30 minutes or less! We will issue all Certificates of Insurance and Additional Insured endorsements that do not require insurance company approval in 30 minutes or less. If you are a new client of Powers & Company, we will issue your Certificate within 30 minues of receiving the policy number.

Items marked with * are required to process this form correctly.

*Contact Name:

*Email:

*Please Issue Certificate To:

Attention:

*Company Name:

*Address:

*City

*State

*Zip Code:

*Phone:

Mobile Phone:

Fax:

*Job Name/Number:

*Description & Location:

*Certificate holder requires
certificate(s) showing coverage for:

	General Liability
	Automobile Liability
	Workers' compensation/ Employer's Liability
	Umbrella Liability
	Professional Liability
	Other:

Special Requirements:
(charges may apply)

	Additional Insured Endorsement
	Waiver of Subrogation
	Primary Wording
	Cross out "endeavor to" and "but failure to mail..." in cancellation section of ACORD form
	Other:

*Sending Instructions:

	Mail original to certificate holder
	Mail original and copy to us
	FAX directly to certificate holder FAX #:

	FAX Certificate to us
	Other:

A Brown and Brown Company