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Request A Certificate

If you are currently a client of Beissel & Cobb Insurance, please complete the form below to request an Insurance Certificate. We will receive your request and process immediately. We will also phone you during regular business hours (Monday through Friday) to confirm receipt of your request. Requests received over the weekend will be processed first thing Monday morning.

If you have any questions, please contact your account manager at 714-838-0601.

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If you prefer, you can download the Certificate Request form. Complete the form and return either via fax or email.

Fax: 1-714-731-7166
Email: acobb@bandcinsurance.com

 

CONTACT INFORMATION

Your Name (required):

Company Name:

Your Email (required)

Telephone:

TYPE OF INSURANCE REQUIRED: (select all needed)

 General Liability

Primary Wording Needed?  Yes No

Waiver of Subrogation?  Yes No

Additional Insured Needed?  Yes No

If an Additional Insured is Required Please Enter Name Here:

 Workers Compensation

Waiver of Subrogation?  Yes No

 Auto

 Professional Liability/E&O

CERTIFICATE HOLDER:

Name:

Street:

City:

State:

Zip:

Attention:

Certificate Holder is:
 Owner  Contractor Sub-contractor Lender Other
If other -please describe:

JOB INFORMATION

Job Location:

Job Description:

Job Start Date:

Job Gross Receipts:

Job Duration:

CANCELLATION

Delete/Endeavor to:  Yes No
 10 Day Notice 30 Day Notice

SPECIAL INSTRUCTIONS

Do you want us to:

 Fax
Fax to number:

Fax to attention:


Email address:

Email to attention:

Do you require a wet/original signature?  yes no

Additional Special Instructions: