Glade & Grove Supply Co., Inc.

of Belle Glade and Pahokee

P.O. Drawer 760, 1006 State Road 80, Belle Glade, FL  33430 «» (561) 996-3095 % (561) 996-8513 Fax

983 New Harvest Road, Immokalee, FL  33934 «» (239) 657-8258 % (239) 657-5381 Fax

P. O. Box 967, Avon Park, FL.  33826 «» (863) 453-3142 % (863) 453-0482 Fax

REQUEST FOR CERTIFICATE OF INSURANCE

PLEASE FAX THIS FORM TO YOUR INSURANCE AGENT IF YOU ARE OBTAINING COVERAGE FROM YOUR INSURANCE AGENT.  IF YOU WISH TO PURCHASE INSURANCE FROM GLADE AND GROVE SUPPLY SIMPLY MARK THE BOX BELOW AND WE WILL FORWARD TO OUR INSURANCE DEPARTMENT FOR PROCESSING.

DATE:___________________

-                                       Check this box if you want to purchase insurance from Glade and Grove Supply Co.

-                      Check this box if you are providing insurance coverage.  The requirements are:

Equipment being rented/demo: 

Unit 1

ModelYear S/N

Value $

  Unit 2

ModelYear S/N

Value $

Unit 3

ModelYear S/N

Value $

Certificate of Insurance Details:

1.      Glade and Grove Supply Co., Inc. will be named the lessor as ADDITIONAL INSURED and LOSS PAYEE.

2.      Lessee shall carry BODILY INJURY and PROPERTY DAMAGE insurance covering the equipment in the combined amounts of not less than $500,000 for each occurrence.

3.      Certificate of Insurance will state that it will give Lessor THIRTY (30) DAYS written notice before the policy in question shall be altered or cancelled and that any proceeds shall be paid jointly to the Lessor and Lessee as their interest may appear.

The Certificate of Insurance can be faxed to the appropriate dealership shown on the top of this page and to the ATTENTION OF: __________________________________.

                                                                                    Sales person

AUTHORIZATION FOR INSURANCE AGENT TO PRODUCE THIS REQUEST.

BY: ­­­­­­­­­­­­­­­­________________________________             SIGNED: ________________________

            Lessee Printed Name