Rhode Island Independent Insurance Agent - Revens-Gates, Inc. Insurance

401-294-9537

Certificate of Insurance

If you are requesting a Certificate of Insurance, please complete the following form:

Client Business Name
Person making request
Contact Phone
Contact E-mail
Certificate Holder Information
Certificate Holder Name
Certificate Holder Street Address
Certificate Holder City
Certificate Holder State, ZIP	ZIP
Job Information
Job Description:
Additional Insured:	yes no
If yes, please describe:
Check applicable coverages:	Worker's Comp. Liability
Please Send Certificate To:
Fax or Mail?	Fax Mail
Fax Number:
Attention:
Special Instructions:
Within 24 hours we will send the certifcate to the holder with a copy to you for your records.

Thank you for your request. We will follow up on your request as soon as possible.