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CERTIFICATE REQUEST INFORMATION
Today's Date :
Date Needed By :
Requested By :
Phone Number:
Requested For:
Phone Number :
Department :
Certificate Holder's Name :
Address Line1 :
Address Line 2 :
City :
State :
Zipcode :
Fax :
Email :
Additional Documentation :
SERVICE NEED
Description of Event (if applicable)
Begin Date :
End Date :
Contact Information
Contact Number
Description:
CANCELLATION CLAUSE
10 Days :
30 Days:
[ ] Days :
COVERAGES
Property :
Liability :
Other, Please List :
SPECIAL INSTRUCTIONS
Instructions
* If the certificate being requested is regarding a vehicle, property, equipment, etc., please provide a complete description including an applicable loan number or lease number if available. The original certificate will be mailed to the Certificate Holder unless otherwise specified. A copy will be forwarded to the Named Insured. For questions concerning this Certificate Request please contact: Client Services Associate cert@goldenbenchmark.com Golden Benchmark Insurance Services, Lic # 0D06566 4588 Peralta Blvd Ste 4 Fremont, CA 94536 Ph: 510-818-9877 Fax: 510-818-9854

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