Certificate of Insurance – (Additionally Insured)

To avoid delays, please also send us any insurance requirements you have been given for this project. You can either fax these to 866-894-7354, or email them to ####.

Policy Holder (MKS Client) Information

Policy Holders (MKS Client) Business Name
Name of Person filling out this form
Your Email

Your CSLB Number

*Only the named insured or authorized persons on behalf of the named insured may request certificates.


Additional Insured’s Information

Business Name

Business Address

City
State
Zip

Contact Name

Phone

Email

Project Location

Project Address

City
State
zip

If multiple project locations, please list all counties where work will be performed

Project Information

1. What is the relationship of the certificate holder or additional insured? - list other
2. Project Setting - list other
3. Work Type - list other
4. Will you be hiring Sub Contractors to help you with this job?
5. Please select ALL trades being performed by your company for this project

 Asbestos Work Fencing Glazing Painting Roofing Boiler Work Finish Carpentry HVAC Parking or Highway Security Equip Cabinetry Fire Protection Insulation/Acoustical Paving Solar Concrete Flooring Landscaping Plastering Swimming Pool Drywall Foundation Low Voltage Plumbing Tile Electrical Masonry Refrigeration Welding Other - list other


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