>    Upon completion this form will be transmitted to KBS.
>    Certificates are issued within 24 hours of our receipt. 
>    We reserve the right to charge for faster service. 
>    For assistance, contact KBS at 1-888-KBS-4321
>    Return to Client Services -- do not submit request.

1.  Today's Date:

2.  Your Company Name:    
     Your Name:          
     Your Title:
     Fax Number: (xxx-xxx-xxxx)    

3.  Issuing Instructions:    Standard (certificate faxed to Holder and copy faxed to you
                                          Mail, do not fax.    Do not send to Holder -- only to us
                                          Other -- please explain: 

4.  Certificate Holder Name: 
     Holder Contact Person:  
     Holder Address:              

     Holder Email:   
     Holder Fax Number:    (xxx-xxx-xxxx)

5.  Show Which Insurance & Privileges Are Desired:   
     Note:  checking boxes other than "Evidence Only"  weakens your coverage and
               is not recommended.  Choose only when necessary or consult KBS staff.

General Liability Evidence Only Addition Insd.  Landlord
 Auto Liability Evidence Only Addition Insd.  Loss Payee
 Building / Property Evidence Only Mortgagee Loss Payee
 Workers Comp. Evidence Only Other: 
 Cargo Evidence Only Other:
 Crime/'Bonding'  Evidence Only  Other:
 Umbrella Liability Evidence Only Other:
 Other:            Evidence Only Other:

 6.  Notification: Insurer will "endeavor to" provide Holder with 10 days notice of cancellation.
                          Check box only if you require something other than this:   (explain below)

7.  Describe Work You Perform for Holder, or Holder's Interest in Having a Certificate Issued:

8.  Comments or Additional Instructions (if any):                          

Thank you!      For assistance contact KBS at 888-KBS-4321.

                 Return to Client Services  (do NOT submit)  

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                                                                      Some artwork copyright by DPA Software.
                                        KBS International Corp.                                                        
                                        914-636-6262 tel.
                                        914-636-0802 fax