To order a certificate to be issued by our office, please complete the form below. Due to the high volume of certificate requests that we receive, please give us 24 hours or the next business day to issue your certificate. There may be additional costs and/or more information needed for Additional Insured's or Waiver of Subrogation.

PLEASE NOTE THAT COMPLETION OF THE FOLLOWING REQUEST FOR INFORMATION DOES NOT CONSTITUTE THE PURCHASE OF INSURANCE. NO COVERAGE MAY BE ADDED, CHANGED  OR BOUND AS A RESULT OF SUBMITTING THIS REQUEST FOR INFORMATION OR QUOTATION INSURANCE. ALL COVERAGE MUST BE CONFIRMED BY THE AGENCY IN WRITING SUBJECT TO AN ACCEPTABLE SIGNED APPLICATION MEETING THE UNDERWRITING GUIDELINES OF THE INSURANCE COMPANY.

For questions, please contact our office at 407-273-0230 or info@jmeyers.com

 

Please Complete The Following Form To Request A Certificate

Required fields are marked with a blue asterisk (*).

Insured Name:

 *

Name Of Person Requesting Certificate:

 *

Policy Number:

 

Insured Fax:

 

Insured Email:

 *

Certificate Holder Name: * (Issue to)

 

Certificate Holder Address Line 1:

 *

Certificate Holder Address Line 2:

 

Certificate Holder City:

 *

Certificate Holder State:

 

Certificate Holder Zip Code:

 *

Attention To:

 

Fax Number:

  

Other Fax Number Or Email:

  

Additional Insured Needed?

 

* Adding additional insured may result in a charge.

Special Requirements Or Comments:

Please indicate how you would like this certificate delivered to the holder:

Please indicate if you would like an insured copy and how it should be sent: