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Request Certificate

Contact Name: *  
Contact Phone Number *  
Contact Email Address: *  
   
Insureds Name:
Certificate Holder Name:
Address:
City:
State:
Zip:
   
General Description
& Comments
Coverages General Liability
Worker's Compensation
Umbrella
Automobile Liability
Automobile Physical Damage
Property / Contents
Equipment
Other
The certificate holder needs to be named as: Additional Insured
Loss Payee
Mortgagee
Primary
Non-Contributory
Waiver of Subrogation
Other
Handling Instructions: Mail Certificate
Fax Certificate:
       Attention:
       Fax Number:
Email Certificate to:
(email address)
   

Please note: This is an alternative method for communicating with us. We will contact you as soon as possible after receiving your request.

info-wdi@leavitt.com

816 5th Street
PO Box 1300
Rapid City, SD 57709
Phone: 605.342.3130

1001 Lazelle Ave
PO Box 490
Sturgis, SD 57785
Phone: 605.347.4583

2011 N. Main
PO Box 98
Spearfish, SD 57783
Phone: 605.642.2624

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