Western Transportation Insurance Services, Inc.

Certificate Request

DATE:
YOUR BUSINESS NAME:
PERSON COMPLETING FORM:
CERTIFICATE HOLDER INFORMATION*
ADDITIONAL INSURED:	Yes No
LOSS PAYEE:	Yes No
RUSH:	Yes No
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE #:
FAX #:
LIABILITY:	Yes No
CARGO:	Yes No
WORK COMP:	Yes No
PHYSICAL DAMAGE:	Yes No
ADDITIONAL REMARKS:

*CERTIFICATE HOLDER INFORMATION MUST BE COMPLETE.
COVERAGES SUBJECT TO POLICY VERIFICATION