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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:
Comments:
Requested By:
Date:
E-mail Address:
© Franklin Insurance Group 2008
