Please fill out the following form, which will be sent to Elizabeth Stanley. If you would like to follow-up with Elizabeth, please call her at 616-531-1900.

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Insured Information
Date:
Contact name:
Phone number:	Ext.
Fax number:
Email address: (Required)
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):
Phone Number:	Ext.
Requesting a Copy of the Certificate (If neither is indicated, we will only send or fax a certificate to the certificate holder)
Please mail 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:
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