Date:
From:
Phone # :
Fax #:
To: Gordon Insurance
Name of Certificate Holder:
Address:
Contact person:
Phone #
Fax #
Location/job site:
Should we FAX or MAIL this certificate?
Fax Mail
Will this Certificate Holder continue next year?
Yes No
Do you wish a copy of this Certificate?
Include as Additional Insured?
Other Comments:
