Commercial Certificate of Insurance Request Form

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  • Requestor Information

  • What is the requestor's first name?
  • What is the requestor's last name?
  • What is today's date?
    MM slash DD slash YYYY
  • What date do you need the certificate of insurance by?
    MM slash DD slash YYYY
  • What is the requestor's phone number?
  • What is the requestor's email address?
  • Please enter any special instructions in the box below.
  • Please upload applicable files here.
    Drop files here or
    Max. file size: 128 MB.

    • Certificate Holder's Information

    • Please enter the certificate holder's name. (Ie. Lender, lessor)
    • Please enter the certificate holder's loan number, if applicable.
    • What is the certificate holder's address?
    • Is there any special language that needs to be included on the certificate?

    • Delivery Method

    • What is the certificate holder's email address?
    • Please enter the certificate holder's fax number.
    • Please enter the address of the Unit Owner or Job Location.
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    Michael Battle

    Michael W. Battle earned a Bachelor of Business Administration (Risk Management) degree from Southern Methodist University. For the last 43 years, he has been a Partner and Director at Keen Battle Mead & Company. Michael has served on Boards of Directors, which include being Past-President of the Independent Insurance Agents of Dade County, Past-President of Riviera Country Club, Past-President of Snapper Creek Lakes Homeowners Association, Past-Chairman of Habitat for Humanity of Greater Miami, Past-Director of the Two Hundred Club of Miami. His Board service on a national business level has included: Director of The Council of Insurance Agents and Brokers, Executive Council of Crum & Forster Insurance Company, and President of Sunshine Insurance Limited, a Bermuda Reinsurance Company. Michael has also served the Florida Association of Insurance Agents as Vice Chair of the Automation Committee, the Legislative Committee, and Chairman of the Local Boards Committee.

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