Kelly Insurance Agency and Life Solutions, Inc.

Please complete and submit the following form to Request a Certificate of Insurance.

Date

Insured Name

Certificate Number

Phone Number

Fax Number

Please answer the following questions:

Is this a one time job?	Yes	No
Should we mail both copies to the insured?	Yes	No
Are there any additional insured?	Yes	No
Please list the additional insured and why

Thank you for contacting us to request a certificate of insurance. If you wish, you may fax the completed Request for a Certificate of Insurance Form to 610-489-6287. Please do not hesitate to contact us personally by phone at 610-489-9442.

Contacting Kelly Insurance Agency & Life Solutions, Inc.:

U.S. Postal Address:	212 West Main Street
	P.O. Box 26811
	Trappe, PA 19426-1919
Phone Number:	610-489-9442
Fax Number:	610-489-6287
Email:	info@kellyins.com


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