Certificate of Insurance Request

Type of Certificate Needed*

Certificate of Liability InsuranceVehicle or Equipment CertificateCertificate of Property InsuranceEvidence of Commercial Property InsuranceCertificate of Garage Insurance

Vehicle or Equipment Year*

Vehicle or Equipment Make*

Vehicle or Equipment Model*

Vehicle or Equipment VIN/Serial Number

If Equipment, What Is The Value?

Vehicle or Equipment Is*

LeasedFinancedOther

Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Holder Company Name (the name listed on the policy)*

Your First Name*

Your Last Name*

Your Email*

example@example.com

Your Phone Number*

Please enter a valid phone number.

Name of Company or Individual Requesting the Certificate? (this is not you, it's the 3rd party requesting it)*

Additional Interest Is*

Additional InsuredLoss PayeeLender's Loss PayableMortgagee

Loan/Lease Number

Address of Company or Individual Requesting the Certificate*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email or fax number to send the certificate of insurance*

List Certificate Requirements Below or Attach Insurance Requirements/Contract

This could include things like being named as additional insured, waiver of subrogation, primary/non-contributory endorsement, etc. If unsure, attached the contract below for our review.

Certificate Requirements or Contract

Additional Comments

By submitting this form you understand the following.

Heritage Insurance's goal is to get all certificate requests processed no later than the next business day.
Some certificate or contract requirements result in the need for a policy endorsement. You will be contacted for confirmation before any changes are made to your policy.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER