Waddell Insurance Group

Evidence of Property Insurance

Please note that this form is for notification purposes and any changes will not be binding until you receive confirmation from us. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST.

I, the policy holder, understand that filling out this form IS NOT binding. Changes ARE ONLY considered binding when I hear back from my agent indicating that they have received my request and will be processing it.

Insured Information:

Indicate if the Certificate Holder is:
Mortgagee	Loss Payee, or	Holder Only

Name
Street or P.O. Box
City
State
Zip
Fax Number
Loan Number if Applicable

Indicate if this Certificate Applies to:

Building

Personal Property, or

Equipment

Equipment	Year	Make	Model	Serial #
Location	Street
	City		State	Zip

Additional Information
In the box below, please provide any additional information you feel may be necessary
for this form.

Requested By:		Date
E-mail Address

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