INSURANCE CERTIFICATE REQUEST FORM - Novick Group, Inc.

INFORMATION ABOUT CERTIFICATE HOLDERFull name and address of organization or entity requiring certificate(s)(We will send certificate TO YOU, but must show the following certificate holder address on the certificate):Name: ________________________________________________________________________________________Address:_______________________________________________________________________________________City: __________________________________ State: ______________________ Zip: _______________________What is this organization’s involvement? ____________________________________________________________________________________________________________________________________________________________Is this organization requesting to be named as an Additional Insured? Yes NoIf yes, Additional Insured – exact language as required by certificate holder (if unsure, you may attach assumption ofliability documents or contract):____________________________________________________________________________________________________________________________________________________________________________________________Is this organization requesting to be named as a Loss Payee? Yes NoIf yes, please describe: _________________________________________________________________________________________________________________________________________________________________________CONTACT TO FAX OR EMAIL CERTIFICATE(S)Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Name: ________________________________________________________________________________________Fax: __________________________________ E­mail: _________________________________________________Fax request to: Attn: Certificates – Fax# 301­795­6610OrEmail to: certificates@novickgroup.comPlease allow at least 48 hours to process request.2