Completion Insured:” ___________ Have the blanks been filled in with the Contractor’s name and address? “Named ___________ Have the row blocks been filled in appropriately? (Note that the Insurance “Company:” Company names will be checked by our personnel with the Mississippi Insurance Commission and the Insurance company names must match exactly as listed with the commission.) No.” ___________ Have the row blocks been filled in appropriately? “Policy Date” Date” ___________ Have the and row blocks been filled in appropriately? “Effective “Expiration Project Number and county? ___________ On the next two (2) blanks of the form, have you typed in the Mississippi Agent or Qualified Nonresident Agent ___________ Has the for the listed insurance companies signed the form beside To be eligible to sign for the insurance company(s) “By:”? the Agent has listed, the Mississippi Agent or Qualified nonresident Agent must possess a Certificate of Authority from the Insurance Commissioner for the listed insurance company(s). If you are not aware how or if such is listed with the Insurance commission, call the Insurance Commission at (601)359-9217 prior to completing this section. (Note, under the signature, you should the Agent’s name because many signatures are not legible.) type ___________ Has the of the Mississippi Agent OR Qualified Nonresident Agent been filled in. “Address:” notarized ___________ Has the document been appropriately? Please utilize this checklist prior to sending the Certificate of Insurance form(s) back because failure to input appropriate information on the will Certificate of Insurance Form(s) result in delayed issuance of the Notice To Proceed.
Completion ___________ Have the “Named Insured:” blanks been filled in with the Contractor’s name and address? ___________ Have the “Company:” row blocks been filled in appropriately? (Note that the Insurance Company names will be checked by our personnel with the Mississippi Insurance Commission and the Insurance company names must match exactly as listed with the commission.) ___________ Have the “Policy No.” row blocks been filled in appropriately? ___________ Have the “Effective Date” and “Expiration Date” row blocks been filled in appropriately? ___________ On the next two (2) blanks of the form, have you typed in the Project Number and county? ___________ Has the Mississippi Agent or Qualified Nonresident Agent for the listed insurance companies signed the form beside “By:”? To be eligible to sign for the insurance company(s) the Agent has listed, the Mississippi Agent or Qualified nonresident Agent must possess a Certificate of Authority from the Insurance Commissioner for the listed insurance company(s). If you are not aware how or if such is listed with the Insurance commission, call the Insurance Commission at (601)359-9217 prior to completing this section. (Note, under the signature, you should type the Agent’s name because many signatures are not legible.) ___________ Has the “Address:” of the Mississippi Agent OR Qualified Nonresident Agent been filled in. ___________ Has the document been notarized appropriately? Please utilize this checklist prior to sending the Certificate of Insurance form(s) back because failure to input appropriate information on the Certificate of Insurance Form(s) will result in delayed issuance of the Notice To Proceed.
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