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Commercial Insurance Certificate Request Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Company Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
Fax #
Optional
E-Mail Address
Required
Company Requesting your Certificate
Company Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
Fax #
Required
E-Mail Address
Required
Lines Of Insurance Needed On Certificate
Optional



Delivery Preference To Holder
Optional


Hold down the Ctrl Key to make multiple selections.
Send A Copy To You?
Optional
Does The Certificate Holder Need To Be Additional Insured?
Optional
If Yes, Which Policies to Add Additional Insured To?
Optional



Add notes here:
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Boer Insurance Group | 2535 Five Mile Road NE, Grand Rapids, MI 49525 | Ph: 616-363-7766 | Fx: 616-363-6626
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