*Please allow two weeks for Certificate requests. This processing time includes  correction of any errors or making changes that are required by the venue.

*Let us know if it is a rush job. Please allow 48 hours for rush certifications.

* Complete all the fields below. Print a copy for your records and hit the "email form" button. This request is delivered into our email inbox.

Certificate Request Form:
Today's Date:
Member's Legal Name
Insured's First Name:
Insured's Last Name:
Email Address:
Business or Performer Name:
Certificate Holder
(Venue where you are performing)
Name:
Attention:
Address:
City:
  State:
Zip Code:
Additional Insured:
Event Date (not required):
Fax Number (where certificate should be sent):
Please check if this is a rush request:
Enter your email address here if you would like a confirmation sent to your email account.
 
     
 
 
Website Design By: Noah Zenzen
Specialty Insurance Agency
Performers of the US & Vendors of the US
PO Box 24
New Richmond, WI 54017
Ph: 715.246.8908
Fax: 715-246-4257
steph@specialtyinsuranceagency.com