Certificate of Insurance Request

If you would like a new certificate of insurance, just complete this form. We will try and have the certificate out to you and the certificate holder within the next hour or so. (During normal business hours!) If you need it sooner, please note that on Page 3 of the form under Special Requirements

1I'm requesting a certificate for...

2The certificate holder is...

3They would like to receive it by...

Person Requesting Certificate*
First Last
Company Name*
Phone*
Email*

Person/Company requiring Certificate (Certificate Holder)*
Attention:
Street Address
City
State
Zip
Coverage(s) Requested for Certificate*
- General Liability
- Excess Liability
- Business Automobile
- Workers Compensation
- Property Coverage

Please send them the certificate by*
- Email
- Fax
- Snail Mail
Email
Fax
Special Requirements
Please tell us if they are requesting to be named as an additional insured; are requesting a waiver of subrogation or other special conditions
Insurance Requirements
Accepted file types: pdf, docx, Max. file size: 39 MB.
Although not required, if you have a pdf document outlining the certificate holders insurance requirements, please upload it here.
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Quote Request Form

"*" indicates required fields

1Products

2Contact Info

3Location

4Docs

5Final Step

Hello! What would you like a quote for?*

Auto

Home / Condo / Renters

Umbrella

Rental Property

Business Owners Package

Check all that apply. You can tell us if there is something else you need a quote for in just a moment.

Primary Policyholder Name*

First Last

Phone*

Email*

Insured Location Address*

Street Address Address Line 2 City State ZIP Code

This is not required, but if readily available, please upload your most current insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider (if you have a login), or from your current agent.

Drop files here or

Max. file size: 39 MB.

What led you to request this quote?*

Internet Search

Facebook Search/Page

Referral

Who referred you to us?*

If you have any other questions, comments or requests, please leave them here

Request Your Proposal Here

Are you ready to save time, aggravation, and money? The team at Farquhar & Black Insurance is here and ready to make the process as painless as possible. We look forward to meeting you!

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