ROBERT HASHIM
INSURANCE SERVICES

 

Certificate of Insurance Request Form (CURRENT CLIENTS ONLY)
 
If you need a Certificate of Insurance, please complete the information below and we will gladly issue the certificate immediately upon receipt of this information.  Please be sure to indicate how we should send it, whether by fax or mail.  We will automatically send you a copy.

Please provide the following information about the certificate holder:

CERTIFICATE HOLDER:
Name:
Address:
Address2
City, State Zip
Fax No:
Attention:
Description: Job?/Landlord?
Additional Insured? **
Should we Fax or Mail?
Your Name
Your Fax #

**  There may be a charge to name an additional insured.  If your policy doesn't already include this, we will contact you with a quote prior to proceeding.

 

PROFESSIONAL RISK MANAGEMENT SINCE 1975

14462 Ipava Dr

Poway, CA 92064

Phone 858-679-1507

Fax 858-679-1230

License #0C17040

Copyright 2007 Robert Hashim Insurance Services. All rights reserved.