Certificate Request Form

At Lovell, we are committed to providing speedy delivery of Certificates of Insurance to our clients. Thus, we have installed a dedicated fax line to accelerate delivery of certificates to you: (212) 269–6059.

You are always welcome to fax or email us a "Request for Certificate of Insurance." We will make our best effort to return the needed certificate, by facsimile transmission, within minutes.

If you wish to print out the Request Form, prepare it and return it to us by fax or mail, please click below. Be sure to use our dedicated fax line, to expedite receipt of a copy of your Workers’ Compensation Certificate: (212) 269–6059. Please send your Request Form to the attention of Certificates Department.

NOTE: This file is a fillable electronic PDF form. Please right-click to download the file and open it in Adobe Reader® to fill it out. Adobe Reader is required to view, complete, save or submit fillable PDF forms. You can download the software for free on the Adobe Web site.

Printable Request Form (FILLABLE)

If you wish to prepare your "Request for Certificate of Insurance" online and submit it to us via this web site, please click below. Again, we will make our best effort to return the needed certificate, by facsimile transmission, within minutes.

Online Request for Certificate of Insurance

Name of Insured:
Policy No.:
If above is an entity, please indicate name of parent company:
Name of individual preparing this request:
Name of Certificate Holder:
Address of Certificate Holder:
 
Check all appropriate boxes below.
Insured
Attention:
Fax No.:
  hard copy only
faxed copy only
both hard copy and fax

Certificate Holder

Attention:
Fax No.:
  hard copy only
faxed copy only
both hard copy and fax
 
 

*If you do not receive your Certificate within one hour, please contact the Certificates Department direct at: certificates@lovellsafety.com or (212) 709-8680.

Watch Our Presentation on Workers' Compensation