John C. Beckett & ASSOCIATES, INC.
 
220 Smith Street
Fort Collins, CO 80524
Phone 970.484.2805
Fax 970.484.2885
800.846.0052
 
 
 
   
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REQUEST A CERTIFICATE OF INSURANCE

Your Name

Name of Your Business

Your Phone Number

Name of Certificate Holder

Address (REQUIRED)

City

State

Fax Number (Optional)

Zip

Job Specific

If YES, name of job

If Certificate Holder is to be listed as an Additional Insured all fields below are REQUIRED.

Additional Insured

Waiver of Subrogation Required

Primary & Noncontributory Wording Required

Number of Days Notice for Cancellation

There will be an additional charge for Additional Insureds

Type of Work You will be performing for Certificate Holder

Is job ongoing or one-time?

Additional Comments
 
     
     
   
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Licensed in the following States: Colorado, Oklahoma, Wyoming, Utah, Arizona, Iowa