Tom Stanger Insurance
Request for Certificate of Insurance
First & Last Name:
Street Address:
City, State & Zip:
E-Mail Address:
Telephone:
Fax:
Recipient Information
First & Last Name:
Street Address:
City, State & Zip:
Telephone:
Fax:
Attention:
Job Reference:
Do you want certificate faxed?
Yes
No
Policies to Reference:
Auto
Umbrella
Work Comp
General Liability
Other
Additional Insured:
Yes
No
If Yes, give details
and which policies:
Waiver of Subrogation:
Yes
No
If Yes, give details
and which policies:
30 Days Notice of Cancellation:
Yes
No
Any Additional Comments or Instructions?
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