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About
- Our Team
- What We Do
Personal Insurance
Commercial Insurance
Submit a Claim
Request a Certificate
News & Events

Request a Certificate2017-09-14T19:11:39+00:00

Request a Certificate of Insurance

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Request for Certificate of Liability Insurance

Submit online form

Download PDF Form

Request for Evidence of Property Insurance

Submit online form

Download PDF Form

Request for Certificate of Liability Insurance

Date*
MM slash DD slash YYYY
Insured Name*
Email*
Requested by (your name)*
Certificate Holder Name*
Certificate Holder Address*
Street Address Address Line 2 City State ZIP Code
PROOF OF INSURANCE*
- General Liability
- Excess Liability
- Automobile
- Worker's Compensation
- Professional Liability
- Crime
- Other
Please Describe*
CERTIFICATE HOLDER IS A/AN*
- Landlord
- Vendor
- Lessor
- Project Related
- Lendor/Mortgagee
- Other
Please Describe*
Description of Job/Auto/Location*
INSURANCE REQUIREMENTS: Additional Insured on General Liability (Check all that apply)*
- Additional Insured on Liability
- Mortgagee
- Cancellation Clause
- Loss Payee on Automobile
- Loss Payee on Property
- Other
Please Describe*
(#) Day of Cancellation*
Please enter a number from 0 to 365.
MAILING INSTRUCTIONS*
- Regular Mail
- Fax to Certificate Holder
- Fax to Insured
- Email to Insured
- Email to Certificate Holder
- Other Instructions
Please Provide Fax Number to Certificate Holder*
Attn*
Please Provide Fax Number to Insured*
Attn*
Insured Email Address*
Certificate Holder Email Address*
Other Instructions

If you have any questions, please contact your Private Client Insurance Services Client Executive, or any of our support team, at 239-481-1949 to assist you.

Request for Evidence of Property Insurance

Date*
MM slash DD slash YYYY
Name of Condo/Townhome Association*
Name of Property Management Company*
Lender Information
Loan #*
Mortgagee*
It’s Successors and/or Assigns ATIMA*
- If needed
- If NOT needed
Address*
Street Address City State ZIP Code
Lender Phone*
Lender Fax*
Email*
Unit Information
Borrower's Name*
Unit's Physical Address (as required on your document)*
Street Address City State ZIP Code
Unit #*
Owner's Information
Owner's Name*
Phone*
Fax*
Email*
Fax To*
- Mortgage Company
- Unit Owner
Attn*
Phone*
Fax*
Email*
COMMENTS/OTHER INSTRUCTIONS

If you have any questions, please contact your Private Client Insurance Services Client Executive, or any of our support team, at 239-481-1949 to assist you.

9736 Commerce Center Court
Fort Myers, FL 33908

Phone: (239) 481-1949

Fax: (239) 481-2911

Email: ContactUs@pcis-fl.com

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