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CERTIFICATE REQUEST

 

Please complete all the required information so we may provide the most accurate certificate of insurance.  Please attach a copy of the request that you received from the insured or certificate holder, including any contracts requiring the certificate.  Please be advised that if an Additional Insured or Waiver of Subrogation is required, there may be additional premium and we will contact you to confirm the cost before providing the certificate.  Please be advised that all certificates will be emailed back to the agency for distribution to the insured and certificate holders.  Please be advised that all certificates for policies issued with Gateway/Pennsy Underwriters, Inc. must be issued by our office only.

 

For any questions, please contact Amy Jones at ajones@gatewaypennsy.com

Your Information

Insured Information

 Certificate Holder Information

Does the Certificate Holder require to be named as Additional Insured or are there any other special requirements (Yes or No - drop down)

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* If YES, please specify which policies and give details below.  Please attache request or contacts at the bottom of the form.  

* Please be advised that if there is additional premium for this request, we will contact you for approval of cost before processing the certificate. 

Does the Certificate Holder require a Waiver of Subrogation? (Yes or No drop down)  

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* If YES, please specify which policies and give details below.  Please attache request or contacts at the bottom of the form.  

* Please be advised that if there is additional premium for this request, we will contact you for approval of cost before processing the certificate. 

Special instructions of additional comments - Please enter any special instructions you feel appropriate for this certificate. 

Please attach any documents that pertain to this certificate request.  

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