Request for Evidence or Certificate of Insurance | Thomas H. Heist Insurance Agency

Our agency would prefer 2 or more business days to complete your certificate request.
• Please complete as much information as possible to avoid any delay in issuance. Proof of coverage will be faxed or e-mailed per your request.

Please provide the following contact information:

Settlement Date, if any --mm/dd/yy

Date Needed --mm/dd/yy

Requested By

Title/Organization

Telephone

FAX

E-Mail

Comment

Please provide the following Insured information:

Insured Property Address

Condo Association Name, if any

Unit Number, if any

Name of Seller

Name of Buyer/Owner

Buyer/Owner Street Address

Buyer/Owner Address(cont.)

Buyer/Owner City

Buyer/Owner State/Province

Buyer/Owner Zip/Postal Code

Buyer/Owner Work Phone

Buyer/Owner Home Phone

Buyer/Owner FAX

Buyer/Owner E-Mail

Please provide the following Lender/Cert Holder information:

Contact Name

Certificate Holder Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Loan Number/Reference Info

Phone

FAX

E-Mail

Certificate Holder Type

Please provide the following Settlement information, if any:

Contact Name

Title Company

Telephone

FAX

E-Mail

Select any of the following options that apply:

Send to Contact By: Fax Email

Send to Mortgage By: Fax Email

Send to Insured By: Fax Email

Send to Title Company By: Fax Email

Click Submit only once

**Coverage can not be increased or decreased by the use of this form. Please contact an underwriter.

This form is sent to our processing department by e-mail. You will receive confirmation of your request within 48 hours. If are not contacted, please contact the office or e-mail tolan@heistinsurance.com if you have problems with this form. Thank you.