How can we help you? "*" indicates required fields Are you a current client of our agency?* Yes No What policy number(s) do you need help with if available? Add RemoveWhat is the nature of your inquiry?* General Question ID Card Request Policy Change Request Discuss A Claim Certificate of Insurance Other Describe your policy change requestWhat date do you need this policy change/request to take effect?* MM slash DD slash YYYY Which vehicle do you need an ID card for (please enter year, make, and model)?YearMakeModel Add RemoveYour Name* First Last Your Email* Your Phone*SMS Follow-up Consent Disclaimer: By checking this box and submitting this form, you consent to receive SMS messages from Lebherz Insurance Agency, Inc at (301) 662-0250 about account notification, customer care or marketing. Message frequency may vary, and standard messaging and data rates may apply. Reply STOP to unsubscribe or HELP for assistance. For more details, see our Terms of Service and Privacy Policy and lebherzinsurance.comWhat type of certificate do you need? Certificate of Liability Insurance Evidence/Certificate of Property Insurance Who do you want to list on this certificate? Another business or individual Nobody, this is only for informational purposes Is there a written contract, agreement, or permit with the certificate holder? No Yes Select "Yes" if you have a written contract, agreement, or permit or have one that is currently being drafted.Who is the certificate holder? A landlord or property manager A vendor A client of yours A lessor - owns equipment your business rents A franchisor - a person or business that sells or grants its business model to a franchise A government agency Other Select any specific wording the certificate holder requires I don't require any wording Additional Insured Waiver of Subrogation Notice of Cancellation Primary and Non-Contributory ATIMA and or ASAOA Job Description/Contract Number Custom wording Job Description/Contract NumberPlease enter specific job description/contract number if certificate holder is requiring it.Custom WordingDon't select custom wording unless the certificate holder asks for special language. You should choose one of the other options for most circumstances. You'll add the certificate holders name in a separate section.Please list the Certificate Holder*This is the name of the 3rd party requesting the certificate, not your name.Are you required to list others as additional insureds in addition to the certificate holder? No Yes Enter the name(s) of the additonal insureds that are in addition to the certificate holderCertificate Holder Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Who should we send the completed certificate to?*Primary emailDetails regarding your question, policy change, claim or other request:*Details regarding your inquiry
