The Fessler Agency | Insurance | Bonds

	3165 McMullen Booth Rd Bldg G2 Clearwater, FL 33761 PH: 727.726.3377 FX: 727.725.4698

Certificate of Insurance Request Form

This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

Insured Information

Insured Making Request:

Address

City, State, Zip

E-Mail

Tel (format with hyphens, ie 727-777-7777)

Fax (format with hyphens, ie 727-777-7777)

Recipient Information
Please issue Certificate of Insurance to the following:

Name:

Address

City, State, Zip

Attention:

Job Reference:

Do you want Certificate faxed?: Yes No

Fax (format with hyphens, ie 727-777-7777)

Certificate Information
Policies to Reference*:

Auto General Liability Workers' Comp

Umbrella Equipment Builders Risk

Unless you specify differently, Auto, General Liability and Workers' Comp willb e the only policies indicated on Certificate (when applicable)

Additional Insured: Yes No
If YES, Specify which policies and give details below:

Waiver of Subrogation: Yes No
If YES, Specify which policies and give details below:

30 Days Notice of Cancellation: Yes No

Please click on the "Submit" button to send your Certificate Request.
One of our representatives will respond to your submission as soon as possible.

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