The Hartford Workers’ Comp Certificate of Insurance Request Named Insured(Required) Policy Number(Required) Who do you want to list on this certificate?(Required) Another business or individual Nobody, this is only for informational purposes (certificate will read ‘For Informational Purposes only) Is there a written contract, agreement or permit with the certificate holder?(Required) Yes No Select 'Yes' if this is currently being completed. Select the certificate holder's relationship to this business:(Required) A landlord or property manager A vendor A lessor - owns equipment this business rents. A franchisor - a person or business that sells or grants its business model to a franchise. A government entity Other - Please explain below ExplanationSelect any specific wording the certificate holder requires:(Required) Waiver of Subrogation Notice of Cancellation Job Description / Contract Number Custom Wording I don't require any special wording. Which state is the job being performed in?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificWhat location are the employees doing this job from?Current insured location on policyNot listed: I've recently added the location to the policy.I need to add a location to the policy. You need to add the location by submitting a change request first. Then you may request the certificate.Wording that will display on certificate: Custom Wording This option needs review. Hartford will check over wording and send this certificate within one business day.Provide the certificate holder’s details: This is the name of the third party requesting the certificate, not your name. Each line has a 39-character limit, including spaces. Please use all three lines if necessary. Name(Required) Name Continued Name Continued Address(Required) City(Required) State(Required) Zip Code(Required) Who should the certificate be sent to?(Required) Additional Email (optional) How often should this certificate be sent?(Required) One time only Every year when the policy renews (Hartford will send the certificate to the email addresses supplied at renewal). Requestor:(Required) Agent Policyholder Full Name Email Agent Email Agency Town
