Las Vegas Insurance Company - Advance Insurance - Las Vegas, NV

 
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Certificate of Insurance Request

Named Insured


Policy Holder Name:
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Requested By:
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Requestors Email:
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Requestors Phone Number:
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Requestors Fax Number:
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Certificate Holder


Name:
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Address 1:
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Address 2:
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City:
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State:
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Zip Code:
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Delivery Information


Preferred Delivery Method:
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Mail Copy to Cert Holder?
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Holder Email:
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Holder Fax Number:
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Attention:
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Certificate Coverages


Please specify which coverage(s) you would like to appear on the certificate of insurance.
General Liability:
Please Select One
Automobile Liability:
Please Select One
Property / Contents:
Please Select One
Equipment:
Please Select One
Umbrella:
Please Select One
Workers Compensation:
Please Select One
Other (specify):
Please Select One

Additional Insured Information


If the certificate holder does not require additional insured status, skip this section. A fee may apply to add an additional insured. Your insurer may charge an increased fee for primary/non-contributory wording and for a waiver of subrogation. We will notify you of the cost, if any, before processing the endorsement.
Additional Insured Status:
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Primary or Non-contributory Wording?
Invalid Input		 Primary and/or non-contributory wording is sometimes requested from the additional insured in a lease or construction agreement. If you are not sure, leave this field blank and fax us a copy of the lease or construction agreement.
Waiver of Subrogation:
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Relationship to Policyholder:







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Notify of Cancellation?
Enter Number Of Days		 Your contract or lease will probably specify the number of days notice we must provide the additional insured, in the event your policy is canceled. If this field is left blank, we will provide a 10-day notice.
Special Wording:
Invalid Input		 Enter any special wording required by the additional insured. If unknown, leave blank

Project Information


For construction projects we require the below information to ensure the scope of work is compliant with your policy. We may also request you provide us a copy of the job contract so we may review the insurance requirements. For LANDLORD certificate requests, please skip this section
Job Description:
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Project Start Date:
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Address of Project:
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Includes NEW CONSTRUCTION for:



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Attention: Please FAX or EMAIL a copy of the contract and insurance requirements to our office, if applicable. Select the appropriate office on our CONTACT US page.


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Contact us

Please contact us at the following.

  • 6290 S. Rainbow Blvd. Las Vegas, NV 89118
  • Telephone: (702) 254-6141
  • Fax: (702) 254-6517
  • Connect with us on Facebook: Las Vegas Insurance