Certificate of Insurance Request Form

Current Watson Insurance Agency clients may request certificates of insurance and evidence of property insurance online. Please note some special requests require insurance carrier approval. We will review your request and contact you with your request status.

Request is for: Certificate of Insurance Evidence of Property Insurance

POLICYHOLDER INFORMATION

Policyholder Name:

*required field

Your Name:

*required field

Address Line 1:

*required field

Address Line 2:

City, State, Zip Code:

*required field

	Contact me by phone:	phone number *required field
	Best time to call:
	Contact me by Email:	email address *required field
	Contact me by Fax:

TYPE OF COVERAGE TO CERTIFY

	Auto, specify vehicle(s):
	General Liability
	Professional Liability
	Umbrella Liability
	Other Liability, specify:
	Property, specify location:
	Workers' Compensation
	Other, please be specific:

CERTIFICATE HOLDER

Certificate Holder's Name:

*required field

Person to Contact:

*required field

Mailing Address Line 1:

*required field

Mailing Address Line 2

City, State, Zip

*required field

Phone:

*required field

Fax certificate to:

Certificate Holder's Interest in your Business:

Mortgagee Loss Payee Landlord
Other, please specify:

Do you provide operations for the Certificate Holder? Yes No

Are the Certificate Holder to be named as Additional Insured? Yes No

Certificate Holder requires days cancellation notice.

Certificate Holder requires Waiver of Subrogation? Yes No

Special Instructions,
Please be specific:

Submitting a request to Watson Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Watson Insurance Agency to confirm binding or altering coverage.


Hosted By: Vow Corporation	Copyright © Watson Insurance Agency