Certificate of Insurance

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Certificate of Insurance
Insured Information
	Insured Name:
	Policy Number:
	Insured Phone Number:
Certificate Information
	Name of Company or Certificate Holder:
	Job Reference Number:
Certificate Holder Street Address:     City:     State:    Zip:
	Certificate Holder Phone:	(include area code)
	Certificate Holder Fax:	(include area code)
	Your Name:
	Contact Email Address:
	Handling Method:	Select Fax Email Snail Mail Pick Up In Person Other
		(if other, please describe in comments area below)
Required Coverages
	Please provide copy of   insurance requirements of contract:	Auto    Umbrella    General Liability     Equipment    Workers' Compensation    Builders Risk
	General Liability Description:
	Need Endorsements for Waiver of Subrogation:	Yes   No
	Need Endorsements for Primary Wording:	Yes   No
	Additional Insured:	Yes   No
	Loss Payee:	Yes   No
	Mortgagee:	Yes   No
Comments or Other Instructions:
Please Note: Insurance coverage cannot be bound without a written binder from our office.

 

  

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Useful Worksheets for Home & Auto

1. Auto Accident Report Form - (to keep in glove box)-PDF
2. Home Inventory Form - (complete before a loss occurs)-PDF
3. Memory Jogger - (for use with home inventory worksheet.)-PDF

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Brier Payne Meade, Topeka – (785) 233-1717
Brier Payne Meade, Kansas City – (913) 402-9576

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