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Bovard Insurance Group - Certificate Request

6950 Squibb Rd., Suite 200
Mission, KS 66202
913-529-1130 phone
913-529-1137 fax

Certificate of Insurance Request (click here for .pdf):

Date *

Insured's Name *

Contact Name *

First

Last

Attention: *

Email *

Fax# *

Mailing Address: *

Delivery Method *

E-Mail Fax Mail

Evidence of Property Insurance *

Yes No

Evidence of Liability Insurance - (Check all that apply) *

General Liability Work Comp Auto Liability Umbrella Professional Liability

If certificate is for a specific job, list specific job description here: *

Is there a written contract with this certificate holder that includes specific insurance requirements? *

Yes No

Is the certificate holder requesting to be added as additional insured? *

Yes No

Bovard Insurance Group - Certificate Request

6950 Squibb Rd., Suite 200
Mission, KS 66202
(913)529-1130 phone
(913)529-1137 fax

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