CERTIFICATE REQUEST

PLEASE COMPLETE THE FORM BELOW TO REQUEST A CERTIFICATE OF INSURANCE

PERSONAL INFORMATIONRequired*

CERTIFICATE RECIPIENT (HOLDER) INFORMATIONRequired*

How would you like us to deliver this certificate?*

JOB INFORMATIONRequired*

ADDITIONAL INSURED INFORMATIONRequired*

WILL YOU BE SENDING SEPARATE ADDITIONAL REQUIREMENTS?*Required*

(SAMPLE CERT, COPY OF CONTRACT)

Sending via:
IMPORTANT: For faster response, include your company name and the request number (top of page) on your email or fax correspondence.

WSR E-Mail: customerservice@wsrinsurance.com

WSR fax number: (770) 426-8601

IF YOU HAVE NOT HEARD BACK FROM US OR THE INSURANCE COMPANY WITHIN TWO BUSINESS DAYS, PLEASE CALL WORLEY, SCHILLING & RANDALL AT (770) 428-1565. THANK YOU.