City of Burlington: Certificate Request

Your Name
First Last
Phone
Your Email Address*
Enter Email Confirm Email
Department
Name of Certificate Holder
First Last
Cert-holder Address
Street Address Address Line 2 City State ZIP Code
Email for Cert Holder
Fax number
Nature of the relationship with the certificate holder
A standard certificate of insurance will be issued with the following applicable coverages: general liability, automobile liability, workers' compensation, and umbrella. If you require other than the standard coverages listed, please list below:
Does the certificate holder need to be included as additional insured?
- Yes
- No
Any special wording or remarks:
Note: Our procedure is to send the certificate directly to the certificate holder and we will email you an original as well for your records. If you would like this certificate handled in a different manner, please list below:

Solutions

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