Certificate of Insurance Request Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Please fill out certificate holder information completely and accurately. Allow 24 to 48 hours for certificates to be processed.

Insured's Information (this is your contact information)

Company Name *

First Name *

Last Name *

Primary Phone Number *

E-Mail Address *

Certificate Holder Information

Information needed is the name and complete address of entity requesting the certificate.

We cannot name the park name, address, or event date on the certificate. If the event is at a city or county owned park, we need the city or county information.

Name *

Street *

City *

State / Province *

ZIP / Postal Code *

Fax Number or Email: *

Is the certificate holder requesting to be named as Additional Insured? *

Yes
No

(Additional Insureds added to the policy may incur additional charges) Unless it is a Florida state park, we cannot name a park as an additional insured.

If you supply us with a fax or email address of the certificate holder we will attempt to send one copy to them. We will email a copy to you for your files.

It is your responsibility to verify with the certificate holder that they have received the certificate and if they have not, to send them a copy.

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Location

2220 Saragossa Ave.
DeLand, FL 32724
Phone: (386) 775-1781
insuranceguy@cfl.rr.com