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Home > Insurance > Certificate Of Insurance Request Form
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Certificate Of Insurance Request Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Contact Information
First Name *
Last Name *
Your Company Name *
E-Mail Address *
Certificate Holder Information
Your certificate of insurance will be issued to the requesting entity as you have entered their information below.
Certificate Holder Name *
Street *
City *
State *
ZIP / Postal Code *
Certificate Holder Email *
Certificate Holder Fax
Send Certificate To

Special Requirements And Endorsements
General Liability






Commercial Auto






Worker's Compensation



Property/Equipment



Project Information
Project Name/Number If Such Reference Is Needed
Comments, Notes, And Special Instructions
Additional premium charges: Your pre-authorization will be required in the event your insurance carrier requires an additional premium charge to satisfy any items requested above.
Important Notice Regarding Certificate of Insurance Requests.
Upon request, we will issue certificates of insurance on our insureds' behalf. Our agency and staff are prohibited from acting as legal advisors or providing legal guidance.
Certificates of insurance we issue will only exhibit the expressly stated insurance limits within our insureds' current policies.
State licensing prevents us from interpreting contracts to identify obligations and/or liabilities.
Certificates of insurance are subject to the terms, conditions, exclusions, regulations, laws, and other provisions of the designated policies they stand for.
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Contact us
Business Insurance: 913.951.2400
Personal Insurance: 913.777.7549
Bukaty Property & Casualty Services, Inc
4601 College Blvd Suite 100
Leawood, KS 66211



Instant Home & Auto Quotes: 913.953.8888
Business Insurance: 913.951.2400
Personal Insurance: 913.777.7549
Fax: 913.562.1392
Email: help@bukatyagency.com
Hours: 8:00 AM – 5:00 PM M-F
Bukaty Companies
Benefits Administration
4601 College Blvd. Ste 100 Leawood KS 66211 913.345.0440

Employee Benefits
4601 College Blvd. Ste 100 Leawood KS 66211 913.345.0440
501 Fay Street, Ste 210 Columbia MO 65201 573.303.0730

Financial Services
4860 College Blvd., Ste 100 Overland Park KS 66211 913.338.5300

Payroll & Accounting
4601 College Blvd. Ste 100 Leawood KS 66211 913.345.0440
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