Skip to main content
#
Call Us Here
About Us
Carriers Represented
Contact Us
Home
Auto Insurance
Condo Insurance
Flood Insurance
Homeowners Insurance
Manufactured Homes Insurance
Motorcycle Insurance
Renters Insurance
Umbrella Insurance
Personal Insurance
Life
Health
Disability
Long Term Care
Dental
Life & Health
Employee Benefits
Annuity
Group Plans
Estate Planning
Financial Services
Customer Service
Free Quotes
Links
Insurance Resources
 Certificate of Insurance 

Certificate of Insurance

Insured Information
Insured Name:
Policy Number:
Insured Phone Number:
Certificate Information
Name of Company or Certificate Holder:
Job Reference Number:
Certificate Holder Street Address:
City:
State: Zip:
Certificate Holder Email Address:
Certificate Holder Fax:
(include area code)
Requesters Information
Your Name:
Contact Email Address:
Handling Method:
(if other, please describe in comments area below)
Required Coverages
Please provide copy of insurance
requirements of contract:
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
Yes No
Need Endorsements for Primary Wording:
Yes No
Additional Insured:
Yes No
Loss Payee:
Yes No
Mortgagee:
Yes No
Comments or Other Instructions

By submitting this form you understand that no coverage is bound until you receive written notice. Changes to policies via this website are not effective or binding until you, or any party involved, receive official notification from your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

 
Insurance That Grows With You

Klemme Insurance Services
PO Box 81149
Midland, TX 79708


 Phone: (432) 687-5646      fax: (432) 684-4428
 email: 
bob@klemmeinsurance.com  

READ OUR PRIVACY STATEMENT

Some Content Provided By: © Insurance Information Institute, Inc. - Used With Permission ALL RIGHTS RESERVED -

Powered By: Insurance Web Designs
websites for insurance agents