Insured's Name: Policy Number: Effective Date of Change: Indicate if the Certificate Holder is: Additional Insured Mortgage Loss Payee Holder Only Name Street or P.O. Box City State Zip Fax Number Loan Number if Applicable If Certificate Holder is an Additional Insured Indicate their Interest: Landlord Charitable Institutions Lessor of Leased Equipment Lessor of Leased Vehicle Municipality Mortgagee General Contrator Property Manager Vendors State or Political Subdivisions - Permits Executors, Administartor, Trustees or Beneficiaries Co-Owners of Insured Premises Grantor of Franchise Controlling Interest Other Other Indicate if this Certificate Applies to: Year: Make: Model: Serial#: Year: Make: Model: Serial#: Street: City: State: Zip: Franklin Insurance Group Representative: Isabel Diego Patricia Acosta Maikel Wong Fernando Alvarez Comments: Requested By: Date: E-mail Address:
