REQUEST A CERTIFICATE OF INSURANCE

Please complete the form to expedite your request for a Certificate of Insurance. Incomplete information may cause a delay in processing request.

Safeco / Liberty Northwest customers

DO NOT COMPLETE THIS REQUEST! Instead please call 888-451-8277, option #3; or email merservice@libertymutual.com to request a certificate.

Zurich customers

DO NOT COMPLETE THIS REQUEST! Instead please call 866-972-2727 or fax 877-397-2329 or email icecenter@zisinternet.com to request a certificate.

Policy number:*
Insured name as shown on policy:*
Address:*
City:*
State:*
Zip Code:*
Your name:*
Your telephone number:*

CERTIFICATE HOLDER INFORMATION
Name of certificate holder:*
Attn:
Address:*
City:*
State:*
Zip code:*
Project name:
Certificate holder is requesting to be listed as:*

PREFERRED METHOD TO ROUTE CERTIFICATE
Method of delivery:*
Delivery info:*

SPECIAL EVENT INFORMATION
Is this request for a special event?*

IF YES, THEN COMPLETE THE FOLLOWING 5 FIELDS
Anticipated number of participants:
Event start date:
Event finish date:
Name of event:
List of activities:
Additional comments:

By selecting "Submit", you agree to provide Glidewell Investments & Insurance Group, Inc., with information about you and/or your organization, that you are an authorized agent and/or representative of the organization submitting this request, and you have the authority to submit this request. In addition, the information provided by you, in this online form, is accurate. You furthermore agree that a representative of Glidewell Investments & Insurance Group, Inc., may contact you in the manner so indicated above. We appreciate your communication!