14221 Metcalf Avenue
Suite 130
Overland Park, KS 66223
Phone 913-402-1700
Fax - 913-402-1727
 

To request a certificate of insurance, please complete the following form.
(If you require a complex certificate with several additional insured's and specific verbiage, please fax the information to 913-402-1727)
 

Your Name
Company Name
Property Address
City
State (Kansas or Missouri Only)
Zip
Email (Required)
Phone
Fax
How should we deliver the certificate?
Certificate Holder Name
Contact Person
Street Address (Or PO Box)
City, ST, Zip Code
Fax
Email (If Applicable)
   
Is This For A Specific Project?  If So, What Is The Project Name?
   
Special Instructions?
 
 
 

Thank you for filling out this form COMPLETELY!

This form is intended for use by only the clients of Mochel Insurance Group.  Please note that certificates of insurance that require special verbiage and or additional insured's may need to be approved by the insurance carrier.  A certificate of insurance does NOT alter or change an insurance policy.