Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Notification Form
     IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications. 

Toll Free: 1.877.644.2766                                                                                                     Providing Insurance Since 1934

 

 
Certificate
of Insurance
Request Form		   This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.
 

 

Insured Information
Insured Making Request:      Date:
Address:
City:    State:    Zip:
Phone:    Fax:
Email Address:


Recipient Information
Please issue Certificate of Insurance to the following:
Name:
Address:
City:    State:    Zip:
Attention:
Job Reference:
Do you want Certificate faxed?: Yes   No         Fax #:


Certificate Information
Policies to Reference*:
Auto  
Umbrella        		 General Liability   Equipment   Workers' Comp.   Builders Risk
*Unless you specify differently, Auto, General Liability and Workers' Comp will be
the only policies indicated on Certificate (when applicable)
Additional Insured: Yes No   If YES, Specify which policies and give details below:
Waiver of Subrogation: Yes No   If YES, Specify which policies and give details below:
30 days Notice of Cancellation: Yes No


Special Instructions
Please give any special instructions you feel appropriate for this certificate.


Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.

 

    

 

This Certificate of Insurance Request Form Copyright by ENHANCED Web Services

Cooper, Simms, Nelson, & Mosley
271 West Canton Avenue, P. O. Box 1480
Winter Park, Florida 32790-1480

Monday - Friday 8:30 a.m. - 5:00 p.m.
Phone: 407-644-8689 Fax 407-644-9934
Toll-free: 877-644-2766
Contact US!

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