Certificate of Insurance Request
Please fill out the following form, which will be sent to Emily Shatto. If you would like to follow-up with Emily, please call her at 616-531-1900.
Insured Information
Date:
Contact Name:
Phone:
Ext
Fax:
Email:
Insured:
Certificate of Insurance requested for:
Name of certificate holder:
Address of certificate holder:
Please send the Certificate by:
Mail
Fax
If by Fax...
Attention:
Fax Number: (please include area code)
Resquesting a Copy of the Certificate
If neither is indicated, we will only send or fax a certificate to the certificate holder.
Please send a copy of this certificate to us (insured)
Please fax a copy of this certificate to us (insured)
Additional Insureds
Name/Address of any additional insured(s) if needed:
Project Name:
Cost of project:
Additional Information or Comments
©2009 Berends Hendricks Stuit Insurance Agency, Inc.
All Rights Reserved.
