Certificate of Insurance Request Form - Sausman Insurance Agency Inc.

Insured's Name:

Phone:

d/b/a:

Fax:

Email:

Types of Insurance to be on certificate (Highlight all that apply): General LiabilityBusiness Auto/TruckingWorkers CompensationOther

Please explain "Other":

What services are you providing or what activities are involved? (Give job number if applicable):

Is there a specific event day or dates the policy holder is providing service:

Is the Certificate Holder requesting any special instructions/request: YesNo

Please explain:

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Certificate Holder Information (* required information)

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Name: *

Address: *

City: *

State: *

Zip: *

Fax: *

Phone: *

Email: *

Contact:

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I accept the Terms and Conditions

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