Cretcher-Lynch & Company

Date:			Contact Name:
			Your Fax # :
Insured / Client Name:

Evidence of Property Insurance

Evidence of Liability Insurance (Check all that apply )

General Liability	Workers Comp	Auto Liability	Umbrella Liability	Professional Liability

Certificate Holder Name & Address:

Certificate Holder Fax # :

For Evidence of Property

Provide Loss Payee Name & Address:

For Liability Insurance Certificate

Job Reference:

Additional Insured:

Special Requirements:

Mail original to certificate holder: Yes No

This is a certicate request for coverage currently in force. You may not bind new coverage by completing this request.