Younts Insurance Agency Cewrtificate Request Form

Younts Insurance Agency, Inc.

Younts Insurance Agency Certificate Request Form

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Insured Name:

Company:

Phone:

Fax:

Please send a Certificate of Insurance to the following:

Company:

ATTN:

Address:

City/State/Zip:

Phone #:

Fax #:

Coverage Requested:

GL AUTO WC UMBRELLA Other

Special Instruction (Project, Additional Insured, Waiver of Subrogation, etc.):

Please feel free to attach corresponding insurance information regarding the request.

YIA would prefer to fax the certificates to both you and the certificate holder. If you would rather have the original/copy mailed, mark here:

Insured Cert. Holder