CERTIFICATE OF INSURANCE REQUEST

              Important notice please read.

          A certificate of insurance provides proof to a vendor/contractor or person that you will be doing business for that you have insurance in place. It provides the name of the insurance company, policy number, effective and expiration dates and limits. In order to issue a certificate, we need the following information. The Certificate holder is the person that has requested the proof of insurance. With the exception of Workers compensation, we can issue a certificate of insurance the same day that it is requested as long as your policy is in full force. Workers compensation that is in the state pool can take up to 5 days to issue and will be mailed direct from the company.

Insured Information

Insured’s Name:*
Dba or Business Name:*
Person Requesting this Certificate:


Certificate Information

Certificate Holder’s Name:
Certificate Holder’s Street Address:
Certificate Holder’s City:  
State:  
Zip Code:  
Certificate Holder’s Phone Number: Voice:   Fax:
Do you need to list the Certificate holder as additional insured Yes No

Policies that you need listed on the certificate:
General Liability  Automobile
Commercial Umbrella Workers Compensation

Additional Comments

293 Bedford Street, PO Box 228, Whitman, MA 02382
781-447-5561 Fax: 781-447-1246

236 Quincy Ave, E. Braintree, MA 02184
781-848-4400 Fax: 781-843-0651
info@myinsuranceman.com