February 22, 2012
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Proof of Property Request
Proof of Property Insurance Request
General Information
Date Needed: *
Named Insured
Account Name:
Address:
City:
Zip Code:
Requested by (enter your name): *
Requestors Email Address: *
Requestors Daytime Phone Number: *
Requestors Fax Number:
Additional Interest
Name: *
Attention:
Address: *
City: *
State: *
Zip Code: *
Additional Insured:
Yes
No
Loss Payee:
Yes
No
Mortgagee:
Yes
No
Other Interest:
Delivery Method
Send Proof?: *
Yes
No
Delivery Method (Please select one): *
Fax
Email
Fax Number:
Email Address:
Attention:
Mail Original to: *
Additional Interest
Insured
Other
Do Not Mail Original
Other Name:
Other Address:
Other City:
Other State:
Other Zip Code:
Required Coverage Information
(*) please provide description below
Limit Required:
Add'l Insured:
Add'l Information
General Liability: (*)
Automobile Liability: (*)
Automobile Physical Damage: (*)
Propert/Contents: (*)
Equipment: (*)
Umbrella: (*)
Workers Compensation:
Other:
Required Coverage Information Description
Please enter description from selections above.
Description:
Additional Insured (please select one):
GL
Auto
Describe Interest of Certificate Holder:
Select Interest Type:
Loss Payee
Mortgagee
Special Instructions
Please Select:
Primary
Non-Contributory
Waiver of Subrogation:
GL
Auto
Workers' Comp
Cancellation:
Yes
No
If Cancellation (please specify):
Other (please specify):
Certificate Information
Description of Operations:
Insuror Letter:
Cancellation Days:
Additional Information
Your Email Address:
Additional Notes:
* = Required Field
Your request will be processed by a representative of Kinker-Eveleigh Agency as promptly as possible once complete information is received. Our turn-around is typically within one business day. Please note that completion of this form does not constitute binding of coverage.
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