Insurance Certificate Request from Miller Hartwig Insurance Agency

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Miller Hartwig
Insurance Agency
P.O. Box 1177
Lakeville, MN 55044

Phone: 952-469-5502
Toll Free: 800-972-4292
Fax: 952-469-1881

we belong to these fine professional associations! we guarantee your satisfaction!

Miller Hartwig Insurance Lakeville Minnesota

"Request Insurance Certificate" Online Order Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your AGENT'S Name:
Your Name
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
Phone (REQUIRED):
Fax: (Optional)

Policy & Service Details (You Must Complete ALL Information Below)
Your Policy Number:


Which do you need?	Certificate of Insurance ONLY -or- Certificate of Insurance WITH Additional Insured Endorsement


Name and Address of Additional Insured:

What is this party's insurable interest to you as named insured (i.e., landlord, permit, for job, etc.)

What is the Additional Insured's relationship to job being performed? (i.e. Owner, managing agent, lessor, general contractor, etc.)

Give complete description of job, and job location:

Describe Job cost, and job duration:

Please contact me for service via:	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please Service My Account. I Understand that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY.

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