CERTIFICATE REQUEST

    PLEASE COMPLETE THE FORM BELOW TO REQUEST A CERTIFICATE OF INSURANCE

    PERSONAL INFORMATIONRequired*

    CERTIFICATE RECIPIENT (HOLDER) INFORMATIONRequired*

    How would you like us to deliver this certificate?*

    JOB INFORMATIONRequired*

    ADDITIONAL INSURED INFORMATIONRequired*

    WILL YOU BE SENDING SEPARATE ADDITIONAL REQUIREMENTS?*Required*

    (SAMPLE CERT, COPY OF CONTRACT)

    Sending via:
    IMPORTANT: For faster response, include your company name and the request number (top of page) on your email or fax correspondence.

    WSR E-Mail: customerservice@wsrinsurance.com

    WSR fax number: (770) 426-8601

    IF YOU HAVE NOT HEARD BACK FROM US OR THE INSURANCE COMPANY WITHIN TWO BUSINESS DAYS, PLEASE CALL WORLEY, SCHILLING & RANDALL AT (770) 428-1565. THANK YOU.