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Additional Insured / Certificate Questionnaire.

Named Insured:Policy Number:
Phone Number:Fax Number:
Email Address:

Entity requesting a Certificate or being Named as Additional Insured: 
Name of Certificate Holder:
Street: City:  
State;Zip: 
Phone:Fax:
Email:

Is Work to be done: New Construction:     Yes   
Remodeling:              Yes    
Service or Repair       Yes    
If New or Remodel work 
give full address of Job:  		Street  City
State   Zip  

Operations of Entity Requesting Cert:                  
Explain Relationship between Named Insured and Additional Insured / Cert Holder
Type of work to be done for Cert Holder/Additional Insured:

 Will the Named Insured be involved in any of the following:
Tract Homes:  ?  Yes   Condos: ?                   Yes   
Apartments: ?     Yes   Town Homes: ?            Yes   

Additional Insured Certificate Information: 
Does the Certificate holder need to be Named Additional Insured?  Yes    
( if yes please complete the following questions A. - H.)

        A. Is there a written contract between the Named Insured and the Additional 
           Insured?                                                                   Yes   

        B. Does the Additional Insured maintain primary insurance to cover the 
            exposure at risk?                                                       Yes   

        C. Contract cost of the work to be done for the Additional Insured? 
                                                                              

        D. Number of Field Employees (include owner as employee) involved on this
            job for Additional Insured:                                

        E. Job Length?         F. Start Date?   
        G. Expected Completion Date? 
        H. Type and % of work subbed out?      



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Target Financial & Insurance Services
6630 Flanders Drive
San Diego, CA 92121

Tel: (800) 450-8013
Fax: (800) 434-8053
Info@targetinsuranceservices.com

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