Wiersma Insurance Agency, LLC

781 Main Street
Whitinsville, MA 01588

Phone: 508-234-6800     Fax: 508-234-4467

Requests received via normal business hours will be processed within 48 hours - sooner when possible. Please call us if you need immediate help. Note that adding additional insured(s) may result in a charge.

Request a Certificate

To receive a copy of your certificate of insurance, please provide the following information:
*=required.

*Date:

*Name of insured:

*Name of certificate holder:

*Street Address of certificate holder:

*City:

*State:   *Zip:

*Fax Number:

*Email:

*Phone:

*Is there any party requesting to be an additional Insured? Yes No

If yes, provide name:

Additional Insured's Interest:

Additional Insured's Job/Property Name:

Additional insured's Location/Address:

Special Requirements:

Comments/Instructions:

Indicated your preferred method of delivery and supply contact information:

Fax Fax number:

Mail Postal address:

Email E-mail address:

times 5 = sixty