Insured-(Client Company Name)

Certificate Holder (Contractor or Vendor)

Additional Information

Waiver of Subrogation

In order for Clear Spring Property And Casualty Company to approve exceptions/changes to Certificates of Coverage for an insured, the following information must be obtained and submitted to CCMSI for review and approval.

NOTE: The carrier MUST approve exceptions/changes to Certificates of Coverage. If the sections are not completed, the request will NOT be approved by the carrier.

What is the expected length of this project (start and end dates if available)?

-or- Approximate Length Of Project (If ongoing please indicate as such)

Number of employees involved in project?

Class code & Exposure amount

Type of goods hauled

Location of Project

Provide specific work description affected by this exception/change, if available

Is the exception/changes being requested or required? If the exception/change is required, please furnish the provision in the contract requiring said exception/change.