Request Certificate

 
Call (248) 651-7321  8:30 a.m. to 5:30 p.m. EST to speak to a member of our licensed & accredited staff
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To help us serve you better, please complete all required information (indicated by an asterisk ( * ) and/or highlighted in light blue).

Your Personal Information
* Your Name:
* Phone:
Fax:
* Named Insured:
NOTE: If you are the insured person, "your name" should match "name insured".


Method of Delivery
Mail to Insured :
Mail to Certificate Holder:
Fax to Insured :
Fax to Certificate Holder:
Certificate Holder's Information
* Name:
* Street Address:
Apt/Suite Number:
* City:
* State:
      * Zip Code:
Phone:
Fax:
 
Additional Information
Name certificate holder as additional insured?
  Yes
No
Is insured doing job for certificate holder?
  Yes
No
Cost of Job:
Date of Job:
Is additional insured named as landlord?
  Yes
No

Other information:

 

Form Submission Agreement:
I agree that by submitting this form the questions were answered to the best of my ability.
I am authorizing Whims Insurance to act upon the information given. 

Please check if you agree to these terms: 

If you entered a valid email address, you will receive a computer generated confirmation that the form has been sent.  We will personally send you an email confirmation once we have received and evaluated your request.

  
 

 

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