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Certificate of Insurance Request

Thank you for allowing us at The Summer Agency Insurance Brokers, Inc. this opportunity to receive your Certificate Of Insurance Request on-line. Please fill out your information in request form below on this webpage. We will respond to your submission promptly.

Attention: Following your completed submission, please FAX or EMAIL a copy of the contract and/or insurance requirements to our office (if applicable).

Certificate Request

Use this form if you are our client or a third party requesting a Certificate of Insurance. (Submission of this form does not automatically change the policy. The coverage will not change until this request is received and confirmed by The Summer Group.)

Your Name (first, last): *
Company Name (Named Insured) *

Enter your business name if a Summer Group client or our insured's company name if you a third party.

Name of the Certificate Holder *

The company that is requesting the certificate of insurance.

Address of Certificate Holder

	Street Address
	Address Line 2
	City
	State / Province / Region
	Postal / Zip Code

Email *

Fax Number - -

Holder is listed as: (select all that apply) Additional Insured Loss Payee

You may select more than one choice.

Where should we send the Certificate? * Directly to the Holder Directly to You Both

If you choose 'Both' enter in the email address or fax number of other party.

If 'Both' enter in fax number or email address to send to other party.

How should we send the Certificate? * Email Fax Mail

Reason for Certificate and other special comments/requests.

Upload File:

Enter Security Code:

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Licensed in the following States: California, Nevada, and Arizona [State License #'s: CA 0664578, NV 519338, AZ 184260]

Our Team Mission:
We at The Summer Group are committed to providing EVERY CLIENT a superior experience exceeding their expectations, by being friendly, focused, having positive attitudes and great teamwork. We Judge Our Success by How Much We Give.

This Web site provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements, or prospectus, if applicable.

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Certificate of Insurance Request

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