Request for a Certificate of Insurance

Please fill this form out as completely as necessary and we will respond as soon as possible.

* = required field

Name

Company

Please issue a Certificate of Insurance For:

Name:

Attn:

Address

Additional Insured:

Yes No

Special Wording Required

Yes No

Send Certificate to:

	Our office
	Certificate Holder
	Certificate Holder’s Fax Number

Comments

3 Corporate Drive Clifton Park, NY 12065 ph: 518.371.0075 fax: 518.371.0675 info@winfieldgroup.com