Request a Certificate

PLEASE NOTE: No coverage of any kind is bound by submitting information via this online form.


Insured Information

Please complete the form below. Items marked with an asterik (*) are required.

Business Name:

Address:

City:

State:

Zip:

Phone:

Person making request:

E-mail:

Fax:

Issue Certificate of Insurance to the following:

Name:

Address:

City:

State:

Zip:

Attention:

Job # or Reference:

Fax certificate to:

Email To:

Other:

Certificate Information

Policies to reference:

30 days notice of cancellation?

Additional Insured?

If yes, please specify which policies and provide details:

Special Instructions:

By completing this form, you are acknowledging your understanding of and agreement with these terms. If you have a contract or paperwork pertaining to the certificate requirements, please fax it to us at 319-365-6919 or email it to certs@millhisersmith.com.