Hortica - Request A Certificate of Insurance

hortica - Insurance & Employee Benefits To guide and provide

Hortica - Request A Certificate of Insurance

- Request A Certificate of Insurance On-line Form -

Your Name and Business

Name

Email Address

Business

Phone Number

Hortica Account #

Certificate Holder Information

Contact Name

Name of Business

Street Address

City

State

Zip

Certificate Holder

Does Certificate Holder need to be named as:

Additional Insured

Loss Payee

If so, what is their interest?

By adding an Additional Insured you are agreeing to share your insurance with the Certificate Holder.
If the Certificate Holder must be named an Additional Insured, submit a copy of the contract or insurance requirements.

Phone Number

Insurance Coverage (check all that are to be included on the certificate)

	Auto Liability		General Liability
	Umbrella Liability		Auto Physical Damage
	Cargo		Workers Compensation

Fax Number

Vehicle Information (complete only if the certificate applies to a specific vehicle or trailer):

Year

Manufacturer

Model

Vehicle ID Number

Cost New

Brief description of work to be performed?

Additional Information?

Check here to acknowledge the following:

1) Certificates of Insurance will be issued consistent with actual policy terms and conditions.

2) Additional Insureds subject to Underwriting Approval

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