Southern Insurance Agency

Certificate of Insurance Request

NAMED INSURED
Account Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Requested by:
enter your name
Requestors Email Address:
Requestors Phone Number:
Requestors Fax Number:
CERTIFICATE HOLDER
Name:
Address 1:
Address 2:
City:
State:
Zip Code:
DELIVERY INFORMATION
Delivery Method (Please select one) Fax  Email
Email Address:
Fax Number:
Attention to:
REQUIRED COVERAGE INFORMATION
(*) please provide description below
  Limit Required: Add'l Insured: Add'l Information
General Liability: (*)
Automobile Liability: (*)
Automobile Physical Damage: (*)
Propert/Contents: (*)
Equipment: (*)
Umbrella: (*)
Workers Compensation:
Other:
REQUIRED COVERAGE INFORMATION DESCRIPTION
Please enter description from selections above.
Description:
Additional Insured:
please select one
GL  Auto
Describe Interest of Certificate Holder
Select Interest Type Loss Payee  Mortgagee
SPECIAL INSTRUCTIONS:
Please Select: Primary  Non-Contributory
Waiver of Subrogation: GL  Auto  Workers' Comp
Other (please specify):
ADDITIONAL INFORMATION
Your Email Address:
Additional Notes:
* = Required Field
Attention: Please FAX or EMAIL a copy of the contract and insurance requirments to our office. - Select LOCATIONS under WHO WE ARE on our menu for the appropriate contact information.

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