Downloadable Forms and Certificate of Insurance

Click the links below to download forms

Standard Certificate of Coverage May 2010 - May 2011

W-9 form (updated for 2010)

Ohio Worker's Compensation form

Fill out the form below to customize a certificate of insurance

Customize a Certificate of Insurance

Preferred method for receiving certificate: * Email Fax E-mail Address: * Fax Number: Full Company Name: * Contact Name: * Complete Address of Certificate Holder: * Interest in Project: * -- Please Select --NoneArchitectContractorEngineeringOwnerSurveyorOther Additional Interest #2: Full Company Name Additional Interest #2: Contact Name: Additional Interest #2: Complete Address of Additional Interest #2 Additional Interest #2: Interest in Project: -- Please Select --NoneArchitectContractorEngineeringOwnerSurveyorOther Additional Interest #3: Full Company Name: Additional Interest #3: Contact Name: Additional Interest #3: Complete Address of Additional Interest #3: Additional Interest #3: Interest in Project -- Please Select --NoneArchitectContractorEngineeringOwnerSurveyorOther For more parties listed as additional interest, attach document: Endorsement Requests by Line of Coverage: * General Liability Auto Liability Workers Compensation Options for General Liability -- Please Select --Additionally InsuredAdditionally Insured w/ Complete Operations Options for Auto Liability: -- Please Select --Additionally Insured State Job is in: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming --Territories-- American Samoa Federated States of Micronesia Guam Midway Islands Puerto Rico U.S. Virgin Islands Project Information: Project Name: * Project Location: * Project Number: Comments: Other Requirements for Certificate: * Required

 

Please note: 1) Amendment of cancellation clause on certificate (Acord 125 form) is not supported. 2) 10-day notice of cancellation applies to all certificates. Orig. 6-10-08.  Property of Knight Crockett Miller Insurance Group, 22 N. Erie St., Toledo, OH  43604. *** Disclaimer *** Filling out this form does not guarantee that GPRS insurance will meet all requirements. This is simply a request form.