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HAYS AFFINITY SOLUTIONS

A MEMBER OF HAYS COMPANIES

Hays Companies of Washington, DC

1250 24th Street, NW – Suite 725

Washington, DC  20037

Phone:  202-263-4024    Fax:  202-263-4001

AIHA Errors and Omissions Insurance Program

REQUEST FOR CERTIFICATE OF INSURANCE

Policyholder Information

Contact Person:  ________________Named Insured: __________________________________

Errors and Omissions Liability Insurance Only     

Certificate for All Policies (if applicable)

Note on Special Insurance Wording and Endorsements

* Certificates requiring special wording or endorsements to non-professional liability coverages (e.g., GL, Auto, Workers’ Comp, etc.) should not be submitted via this request form. Requests for such special wording on non-professional liability coverages should be directed to The Hartford Insurance Company (per their request). Fax your contact information along with your Hartford Policy number(s) with your request to 704-921-4675 attn: The Hartford Policy Change Team - do not use this form.  Additional questions on these matters can be directed to The Hartford Insurance @ 1-866-467-8730.

Certificate Holder Information  Additional Insured (only applies to GL)

Organization Name:

Mailing Address:

City: State: ZIP Code:

Contact Person: Fax:

I wish to receive a copy of this Certificate via Fax OR email (include number OR email address on line below) :  

    Fax #: ________________________________Email address: _____________________________________

Fax a copy  of the certificate of insurance to Certificate Holder.  Mail original to client(s)

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