DICKINSON INSURANCE CLIENT SERVICES

Order your Certificates of Insurance Online 24/7! Filling out this form will send a direct email to a Client Services Agent who will send you a confirmation of receipt via email, and complete your certificate request in a timely and professional manner.

CLIENT INFORMATION

	Client's Name
	Your Full Name
	Company Name (Company REQUESTING Certificate)
	Company Mailing Address

7 EASY CERTIFICATE INSTRUCTION QUESTIONS...

	If you are doing any of the types of work on this list, please indicate:

	Briefly describe the type of work:
	Provide a BRIEF description here.

	Provide the job location:
	In the absence of an address, provide cross streets and the city.

	Cost & Length of Job:

	Does anyone need to be named additional insured?
		If yes, give name and address.

	Is "Endeavor to.." and "But failure to mail.." need to be lined out?

	Additional wording or instructions, if any.

CERTIFICATE DELIVERY INSTRUCTIONS

	Does certificate need to be faxed?
	Fax the certificate to...
	Fax the certificate to the attention of...
	Fax Number
Certificate Requirements can be confusing, If you are not sure just fill out this form and fax us the requirements at (208) 773-2805.