Get Service > Insurance Certificate - Request Copy
Return to Previous Page
Crosby & Henry can fax to you an insurance certificate, or proof of insurance. Fill out the form below. Please fill in ALL fields, or we may not be able to respond. Click Submit, and a Crosby & Henry representative will process your request during regular business hours.
NAME/ADDRESS OF INSURED:
Name:
Address:
City:
State/Zip:
Email Address:
Telephone Number:
Fax Number:
COVERAGES TO BE SHOWN:
General Liability Automobile
Worker's Comp Other (specify below:)
Umbrella - Excess Liability
CERTIFICATE HOLDER:
Name:
DBA:
Address:
City:
State/Zip:
Email Address:
(Required to respond)
Telephone Number:
Fax Number:
CERTIFICATE HOLDER'S INTEREST:
Loss Payee Additional Insured (describe reason)
Vendor
Mortgage Payee Other (describe)
OTHER REQUIREMENTS:
Describe any
additional
specifications:

Certificates are only issued to verify coverage currently in force. To add, change or bind additional coverage, you need to speak with one of the insurance professionals at Crosby & Henry .