CERTIFICATE REQUEST

To:

 Lykes Insurance, Inc.

Date of Request:

 mm /dd/yy

Fax:

 813-221-1837

Attn:

Please send certificate for:
(Your Company Name)

Certificate Holder:

Attention:

Certificate Holder Name:
Address:
Address (second line):
City:
State:
Zip:
Phone Number:
 Fax:

Coverage:

Liability
Work Comp
Auto
Other (Enter description)

Request:

10 day  30 day  60 day Cancellation (please select one)
Additional Insured
Hold Harmless
Mortgage
Waiver of Subrogation
Loss Payee RE:  (Item/location/car/equipment, etc.)

Please Send Via...

 

 Mail
Fax:
Fax Number(xxx-xxx-xxxx)
Account Number (Required)

Name of Project
(if required):

Special Instructions:

Requested by:

Phone Number:



Please note that completion of the above request for information does not constitute the purchase of insurance. No coverage my be bound or amended via submission of this request for information or quotation of 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.