Certificate of Insurance Request

You can process and print a certificate using the CSR 24/7 link. If you are not set up to issue certificates directly using CSR 24/7, please call our office at 816-781-4922 to get signed up and receive a brief training for this free service. Otherwise, please complete the request form and a certificate will be processed by our office and faxed/mailed/e-mailed to the certificate holder with a copy to your attention. You may also fax your certificate request to our office at 816-781-8050 or e-mail the request directly to your Licensed Service Representative

*Date:

*Email:

*Contact Name:

*Fax Number:

*Insured / Client Name:

Evidence of Property Insurance

Evidence of Liability Insurance (Check all that apply)

General Liability

Workers Comp

Auto Liability

Umbrella Liability

Professional Liability

Other Liability

Name & Address

Fax Number:

Email Address:

Provide loss payee name & Address

Job References:

Additional Insured:

Special Requirements:

Attachments:

Send This File: (Max Size 20 MB)

Mail original to certificate holder:

Yes

No

* This is a certicate request for coverage currently in force. You may not bind new coverage by completing this request.