CERTIFICATE/EVIDENCE OF
INSURANCE REQUEST

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
* Indicates required fields

    CERTIFICATE NEEDED NO LATER THAN:

    Type of Customer*:Personal CustomerCommercial Customer

    Insured Information

    Insured or Company Name*:
    Your Name(if different):
    Phone Number:
    Insured Email:
    Fax Number:
    Policy Number:

    Type of Form Needed:

     

    COMMERCIAL CERTIFICATE OR EVIDENCE OF PROPERTY (Certificate Holder refers to the name of the person/entity requesting proof of coverage)

    Certificate Holder Name:*


    Attention:
    Holder Address:*
    Holder Address 2:
    Holder City/ST/Zip:*
    Holder Phone #:
    Holder E-Mail:
    Holder Fax #:

    Delivery Method:

    CERTIFICATE DESCRIPTION: (i.e., description of operation for which you need certificate. If the holder has requested specific wording for the certificate, please put here as well.) (e.g. For Contracted Work of Insured at Certificate Holder location at 1234 Main St., Any town MI 48888)

     

    Certificate Holder, Nature of Interest*(Check all that apply)

    NO INTERESTAdditional InsuredLoss PayeeLender Loss PayeeAdd'l Insd-Loss PayeeAdd'l Insd-Lndr Loss PayeeMortgageeHold HarmlessLeinholderLessor**

    ** If Lessor (Specify what is being leased and it's value in NOTES below)

    Lines of Business to Include* (Check all that apply)

    ALL LINESCOMMERCIAL LIABILITY COMMERCIAL AUTO WORK COMPUMBRELLAPROPERTY-REALPROPERTY-CONTENTSPROPERTY-EQUIPMENTPROFESSIONAL LIABILITYHOME OWNERS

     

    Notes:

    Attachments:

    If you have a sample from the Certificate Holder or certain portions of a contract that specify what is needed, please attach here.



    Name of person completing form:*

    Confirmation Email Address:*

    (We need this to send you a confirmation receipt for this form.)