Bizurance - Where Business Goes for Insurance

Call Us: (502) 365-9805

Request a Certificate of Insurance

Named Insured

Requested by/Company Name

Requestor's Phone Number

Requestor's Fax Number

Requestor's Email Address

Certificate Holder Information

Company Name

Contact Name

Mailing Address #1




Phone Number

Email Address

Coverage Information

Type of Insurance

Description of Property/Operation

Additional Insured Requested

Loss Payee Requested

Mortgagee Requested

If you answered yes above, it's mandatory to detail the reason(s)

Certificate to Holder

Certificate to Insured

Date Certificate Needed

Certificate Holder's Fax Number

Important Notice

Bizurance cannot bind, modify or cancel coverage via submissions to our website or by messages sent through e-mail. Completion and submission of this form or e-mail does not constitute either a binder or an application for insurance.  Changes to policies are not effective or binding until you or any party involved receive official notice from either a Bizurance representative or your insurance company.  If you have any questions, please feel free to Contact Us.