Request a Certificate -

Request A Certificate of Insurance

PLEASE DO NOT COMPLETE THIS FORM IF YOU DO NOT ALREADY HAVE INSURANCE COVERAGE WITH TAYLOR AND TAYLOR.

TO APPLY FOR COVERAGE PLEASE REFER TO THE PROGRAMS SECTION OF THIS WEBSITE OR CALL US AT (212) 490-8511.

General Information

Name of Insured *

Email (yours) *

Account Manager *

This is the person who handles your account at Taylor & Taylor Associates.

Dates of Project

Effective Date

Expiration Date

Address of Shoot

Country

City

State

Zip code

Contact Information

Name of Certificate Holder *

Address of Certificate Holder *

Country

City

State

Zip code

Contact Name

Contact Phone

Contact Email

Date Certificate Required *

Date by which the certificate of insurance is needed.

Certificate holder is:

Check one:

Additional Insured - Landlord for a location

Additional Insured - Municipality for a permit

Additional Insured and Loss Payee for Leased Equipment

Loss Payee ONLY for Leased Equipment

Certificate is issued for Evidence of Insurance ONLY

Leased Equipment Description

Include replacement cost value and lease dates (please include the year, make and model when renting vehicles)

Project Description

Include title of project and location.

Send Certificate Via:

Check one (and fill out info):

Select at least one delivery method. If you need a multiple of methods or copies of certificates, please indicate that in the Additional Instructions field below.

Fax Certificate

Mail Original Copy

Overnight Certificate

Email Certificate

Attention

Fax Number

Attention (additional)

Fax Number (additional)

Recipient is:

Name

Company

Address

Country

City

State

Zip code

Fed Ex Account No:

Name

Company

Address

Country

City

State

Zip code

Email certificate to: *

Additional Instructions

If you need to send a certificate to multiple people or with a combination of sending methods, please add these instructions here:

Form Verification (this proves you're not a robot!)

Please enter any two digits with no spaces (Example: 12) *