Ferranti Leavitt Insurance Agency

408 East Main
Hermiston, OR 97838
Phone: 541-567-5523
Fax: 866-663-5643

Request Certificate

Contact Name:	*
Contact Phone Number	*
Contact Email Address:	*

Insureds Name:
Certificate Holder Name:
Address:
City:
State:
Zip:

General Description & Comments
Coverages	General Liability Worker's Compensation Umbrella Automobile Liability Automobile Physical Damage Property / Contents Equipment Other
The certificate holder needs to be named as:	Additional Insured Loss Payee Mortgagee Primary Non-Contributory Waiver of Subrogation Other
Handling Instructions:	Mail Certificate Fax Certificate: Attention: Fax Number: Email Certificate to: (email address)

Please note: This is an alternative method for communicating with us. We will contact you as soon as possible after receiving your request.