KMA INC . Certificate Request

CERTIFICATE OF INSURANCE REQUEST FORM

Instructions

Complete this form and email, fax or mail a copy of the certificate/insurance requirements from the organization requesting the certificate (if applicable) to:

KMA, Inc., 1831 121 Street East, Burnsville, MN 55337
Facsimile:1.952.944.2713

The certificate will be issued within 24 hours of receipt.
Special requests may take longer to process.
Questions? Call KMA toll-free at: 1.800.611.9812

Named Insured/Division Information
Named Insured:	Urgent Standard Service
Division Name:	Contract Attached:	Yes No
Contact Name	Phone:

Certificate Holder Information (What entity is requesting proof of insurance?)
Name:
Address:
Contract:
Contract Number (Job Number)(if Applicable):

Special Coverages Required
	Additional Insured(General Liability, Automobile, Umbrella)
	Waiver of Subrogation ( General Liability &/or Workers' Compensation)
	Primary/Non-Contributory Wording
	Alternate Employer Endorsement (WC Only)
	Professional Liability-Additional Insured Requirement
	Crime-Third Party Coverage Requirement (Employee Dishonesty)
	30 Day Notice of Cancellation
	Standard Certificate-No contractual wording required
Contracts that require specific policy forms and/or contract language may require additional underwriting and cost associated with specific endorsements to be issued.

Distribution of Certificate(Send Original Certificate Instructions)
	Mail direct to Certificate Holder		Email direct to Insured Contact:
	Fax to Certificate Holder	Fax Number:		Contact:

The Request Form illustrates basic terms and conditions and is intended as a reference guide only. The form does not include all policy conditions. If there are any variations between this document and the policies, the policies will govern.