MERCER INSURANCE & FINANCIAL
SERVICE AGENCY
FAQ
ABOUT US POLICYHOLDERS LINKS
HOME OUR STAFF REQUEST INFO CONTACT US
"Certificate of Insurance" Request Form
One Simple Form: Takes 2-3 minutes to complete
Personal Information:
Your Name:
Business Name (If Applicable):
Street Address:
City:
State:
Zip/Postal:
Email Address:
Phone Number:
Fax Number (Optional):
Policy Details:
Policy Number:
Name & Address of Additional Insured
if required:
How shall we send your Certificate: Mail Copies Fax Copies Mail AND Fax Copies
Additional Information:
If you're requesting this service by fax, please indicate the fax number if different than the number above. If we are sending it to someone other than yourself, who's attention should it read?
If you need an ID Card for your vehicle(s), please type which vehicle(s).
Yes, please service my policy. I understand that NO COVERAGE IS BOUND for any changes made to my policy until confirmed IN WRITING by a Mercer Insurance Represenative.
Thank you for filling out this form COMPLETELY!
Providing service to Michigan residents and businesses since 1988
725 W ELLSWORTH RD.  ANN ARBOR, MICHIGAN 48108   (734)996-4044   [email protected]
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