Thomas E. Sears Insurance Agency, Inc.
Complete the following information for a Certificate of Insurance:
First Name:
Last Name:
Phone:
Email:
Business name:
Certificate Holder Information
Name:
Address:
Address:
City:
State:
Zip:
Is any party requesting to be added as an "Additional Insured"?
If YES, name:
Additional insured's interest:
If OTHER, explain:
Description of job being performed (i.e. type, location, duration):
Phone:
Fax:
(978) 562-3464 (508) 234-6275
