Submitted By:

Company:

E-Mail:

The Barkley Group, LLC should process this request as:

Normal (within 3 days)

Certificate should indicate the following: (choose all that apply)

All Coverage In Force

Automobile Liability / Physical Damage

General Liability

Property

Umbrella

Workers' Compensation

Certificate Holder Name and Address:

Certificate Holder is: (choose all that apply)

Additional Insured

Building Owner

Contractor

Customer

Landlord

Lessor of Equipment

Loss Payee

Mortgagee

Second Mortgage

Other

Additional Insured (if different than the Certificate Holder)

Description of Operations, Location, Vehicles or Special Wording:

Distribution

A copy will automatically be faxed to you, check all others that apply:

Fax to Certificate Holder

Attention

Fax #

Also Fax to:

Fax Number:

Mail Original to Certificate Holder

Mail Copy to Additional Insured

Mail Original to Insured

Email Confirmation Certificate has been Mailed

Certificate Holder's Email Address