Meadors Adams & LeeCertificate Request A certificate of insurance is a document used to verify if an entity is insured. Policyholders can make a request for a Certificate of Insurance to be issued to a third party. Our Insured Company NameRequester First Last Phone NumberEmail Certificate Holder Company NamePhone NumberFax NumberHolder Email Holder Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Job Reference Check All That Apply: Property General Liability Workers Compensation Auto Umbrella Other Add Certificate Holder As: Additional Insured Lienholder Mortgagee Loss Payee General Certificate Holder Only Specific Information to be shown on CertificateCancellation Notice to be shown on CertificatePreferred Method to Receive Certificate Fax Email NameThis field is for validation purposes and should be left unchanged. 4227