Contact Us  |  April 25, 2017

Proof of Property Insurance Request

General Information
Date Needed: *
Named Insured
Account Name:
Address:
City:
Zip Code:
Requested by (enter your name): *
Requestors Email Address: *
Requestors Daytime Phone Number: *
Requestors Fax Number:
Additional Interest
Name: *
Attention:
Address: *
City: *
State: *
Zip Code: *
Additional Insured: Yes  No
Loss Payee: Yes  No
Mortgagee: Yes  No
Other Interest:
Delivery Method
Send Proof?: * Yes  No
Delivery Method (Please select one): * Fax  Email
Fax Number:
Email Address:
Attention:
Mail Original to: * Additional Interest  Insured  Other  Do Not Mail Original
Other Name:
Other Address:
Other City:
Other State:
Other Zip Code:
Required Coverage Information
(*) please provide description below
  Limit Required: Add'l Insured: Add'l Information
General Liability: (*)
Automobile Liability: (*)
Automobile Physical Damage: (*)
Propert/Contents: (*)
Equipment: (*)
Umbrella: (*)
Workers Compensation:
Other:
Required Coverage Information Description
Please enter description from selections above.
Description:
Additional Insured (please select one): GL  Auto
Describe Interest of Certificate Holder:
Select Interest Type: Loss Payee  Mortgagee
Special Instructions
Please Select: Primary  Non-Contributory
Waiver of Subrogation: GL  Auto  Workers' Comp
Cancellation: Yes  No
If Cancellation (please specify):
Other (please specify):
Certificate Information
Description of Operations:
Insuror Letter:
Cancellation Days:
Additional Information
Your Email Address:
Additional Notes:
* = Required Field
Your request will be processed by a representative of Marsh & McLennan Agency LLC (formerly Kinker-Eveleigh Agency) as promptly as possible once complete information is received. Our turn-around is typically within one business day. Please note that completion of this form does not constitute binding of coverage.