Requesting a Certificate of Insurance

Phone: (508) 347-9343 Fax: (508) 347-5798 Email:


	Requesting a Certificate of Insurance Please use the below form to make a certificate request Please be advised it could take up to 48 hours (2 business days) to complete your request.

CERTIFICATE REQUEST FORM
Your Name *:
Your Email:
Phone*:	- -
Best time to contact you.	AM PM
Please issue a Certificate of Insurance to the following name & address
Name*:
Attention To*:
Mailing Address*:
City*:	State* Zip*
Certificate needs to show:
	(please choose all that apply) All current policies Commercial Auto Commercial Umbrella General Liability Worker's Comp Other:
Yes No	Additional Insured Status Required?
Yes No	Do you have a written contract?
What is the duration of the job?	Start Date: End Date: Job Description:
DELIVERY INSTRUCTIONS
If you would like us to fax the certificate. Please provide the below details.
Fax Number: - -
Fax Attn To: Please supply your fax number if you would like a copy sent to you also.
My Fax Number: - -
Please mail originals to certificate holder Mail originals to me (you wish to forward)
Special Requests or Comments:
Privacy and Security
McCurdy Group takes seriously the protection of information you share with us. Law regulates the collection, use and disclosure of such information. For additional details, please review our privacy policy, online security information and terms & conditions. I have read the privacy policy and terms & conditions and want to continue. Please Note: Insurance coverage cannot be bound without a written binder from our office .