Name of Insured:
Your Email:
Who Handles Your Account at Taylor & Taylor:
Date's of Shoot:
Address of Shoot:
Name of Certificate Holder:
Address of Certificate Holder:
City/Zip of Certificate Holder:
Contact Name:
Contact Phone:
Date Certificate of Insurance is needed by:

Check One: Certificate Holder is	Additional Insured - Landlord for a location Additional Insured - Municipality for a permit Additional Insured & Loss Payee for Leased Equipment** Loss Payee ONLY for Leased Equipment** Certificate is issued for Evidence of Insurance ONLY
** Description of Rented Equipment including Replacement Cost Value and Lease Dates.
(Please include the year, make and model when renting vehicles)

Check One (And fill out the information beneath it.):
FAX Certificate to:	Mail Original Copy to:	Overnight Certificate to:
ATTN FAX ATTN FAX	Certificate Holder Other Name Company Addr City/ST/Zip	Fed Ex Acct No: Name Company Addr City/ST/Zip

e-mail Address: nystaff@taylorinsurance.com

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Thank You!