Certificate of Insurance Request

Named Insured

Account Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Requested By

Requestor's Email Address

Requestor's Phone Number

Requestor's Fax Number

Certificate Holder

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Delivery Information

Delivery Method

Email
Fax

Email Address

Fax

Attention To

Required Coverage Information

Coverage Information

General Liability Limit Required

General Liability Additional Information

Automotive Liability Limit Required

Automotive Liability Additional Information

Automotive Physical Damage Limit Required

Additional Umbrella Waiver

Automotive Physical Damage Additional Information

Property/Contents Limit Required

Property/Contents Additional Information

Equipment Limit Required

Equipment Additional Information

Umbrella Limit Required

Umbrella Additional Information

Workers Compensation Limit Required

Workers Compensation Additional Information

Other Limit Required

Other Additional Information

Required Coverage Information Details

Additional Insured

GL
Auto

Describe Interest of Certificate Holder

Select Interest Type

Loss Payee
Mortgagee

Special Instructions

Please select

Primary
Non-Contributory

Waiver of Subrogation

GL
Auto
Workers Comp
Other

Cancellation

Yes
No

If Cancellation (please specify)

Other (please specify)

Certificate Information

Description of Operations

Insurer Letter

Yes

Cancellation Days

Additional Information

Your Email Address

Additional Notes

Disclaimer

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Tawas Bay Insurance Agency.

Attention: Please FAX a copy of the contract and insurance requirements to (989) 362-5131

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