LIABILITY/GENERAL AND AUTO

 
 

 

 

print this form (optional)

12155 Metro Parkway, Ste. 28A
Ft.Myers FL 331928302
Phone: (239) 561-3400   (800) 927-0418
Fax: (239) 561-0496
rod@gsiinsurance.com
     
 

REQUEST FOR
CERTIFICATE OF INSURANCE

  
 
INSURED'S NAME Aapiansting, Inc
  dba Sunshine State Bee Removal
   
REQUESTED BY

DATE
       
   

FAX
CERTIFICATE HOLDER:      
COMPANY NAME    
ADDRESS    
ATTN    
       
MAILED TO SAME   / OR:    
     
     
     
     
       
Does this certificate holder have any special requests?      
       
Additional Insured VIN1
Loss Payee VIN2
Lien holder    
30 day cancellation    
Other    
     
     
Please attach a sample certificate or letter with requirements if you have one to :rod@gsiinsurance.com
       
Please note: you can also request a certificate via email: certificates@gsiinsurance.com