Insurance Certificate Request Form

"*" indicates required fields

Named Insured Information

Your Name*

Business Name of Insured*

Your E-mail Address*

Your Phone Number*

Certificate Holder Information

Full and Complete Certificate Holder Company Name*

Address of Certificate Holder

Street Address Address Line 2 City State ZIP Code

Certificate Holder Requester Contact Name

Certificate Holder Requester Email

What is your Relationship with the Cert Holder or What Type of Work will you Perform for this Cert Holder?*

Additional Requirements

Does your Certificate Holder require you to add them as an "ADDITIONAL INSURED"?*

Yes

Does your Certificate Holder require a "WAIVER OF SUBROGATION"?*

Yes

Does your Certificate Holder require other special language (Primary Non-Contributory, 30-Day Notice)?*

Yes

Additional Insured Name(s)

File Upload (attach any relevant documents)

Max. file size: 2 GB.

Comments

Our Mission

Our mission is simply stated, yet earnest. We provide families and business owners peace of mind by safeguarding their assets through risk management expertise. Our proven process ensures you understand your risk tolerance while feeling informed, educated, and protected.

How Can We Help?

Wayzata

1907 Wayzata Blvd Ste 210,
Wayzata, MN 55391

Call or Text

952-930-3661

Hours

Mon. – Thurs.: 8:00 am – 4:30 pm
Friday 8:00 am – 2:00 pm

Coon Rapids

8960 Springbrook Drive, Suite 100
Coon Rapids, MN 55433

Call or Text

763-755-7000

Hours

Mon. – Thurs.: 8:00 am – 4:30 pm
Friday 8:00 am – 2:00 pm