Velco: Certificate Request - Hickok & Boardman Insurance Group

Your Name

First Last

Phone

Your email address*

Enter Email Confirm Email

Department

Name of Certificate Holder

First Last

Cert-holder Address

Street Address Address Line 2 City State ZIP Code

Fax number

Email Address*

Nature of the relationship with the certificate holder

A standard certificate of insurance will be issued with the following applicable coverages: general liability, automobile liability, workers' compensation, and umbrella. If you require other than the standard coverages listed, please list below:

Does the certificate holder need to be included as additional insured?

Yes
No

Any special wording or remarks:

Note: Our procedure is to send the certificate directly to the certificate holder and we will email you an original as well for your records. If you would like this certificate handled in a different manner, please list below:

Velco: Certificate of Insurance

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