Certificate Request

Your Company Information

Company - Nombre de tu Compañia

Email - Tu Email

Certificate Holder Information

Name of Your Client - Nombre de tu Cliente

Address - Direccion de la Compañia

State - Estado

City - Cuidad

Zip Code

Phone Number - Teléfono de la Compañia

Certificate Holder Email - Email de la Compañia

(Optional) Attach a Sample Certificate

(Optional) Waiver Information

Is the client requesting a waiver of subrogation?

Fax number for faxing certificate

Waiver of Subrogation

In order for Clear Spring Property And Casualty Company to approve exceptions/changes to Certificates of Coverage for an insured, the following information must be obtained and submitted to CCMSI for review and approval.

NOTE: The carrier MUST approve exceptions/changes to Certificates of Coverage. If the sections are not completed, the request will NOT be approved by the carrier.

What is the expected length of this project (start and end dates if available)?

-or- Approximate Length Of Project (If ongoing please indicate as such)

Number of employees involved in project?

Class code & Exposure amount

Type of goods hauled

Location of Project

Provide specific work description affected by this exception/change, if available

Is the exception/changes being requested or required? If the exception/change is required, please furnish the provision in the contract requiring said exception/change.

Requested

Required

Additional instructions or requests?

I acknowledge that the information entered here is true and correct. I understand that once submitted, the cert can not be changed or modified unless I request a change. I understand that if I request a waiver of subrogation, their will be a $200 fee for each waiver of subrogation. I also agree to the OCMI III, Inc. dba P.E.O.PayGo terms & conditions.