The Shannon Agency » Certificate Of Insurance Request Form

June 4, 2019

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The Shannon Agency
Timothy G. Shannon, CLF, AIM, LUTCF

Phone: (800) 999-5729
Fax: (877) 625-9370

Recipient Information Please issue Certificate of Insurance to the following:
Name*:
Address:
City:
State:
Zip:
Attention:
Job Reference:
Do you want Certificate Faxed?:	YesNo

Certificate Information
Policies to Reference (please check all that apply):	AutoGeneral LiabilityWorkers' Comp.EquipmentBuilders RiskUmbrella
Additional Insured:	YesNo
If yes, specify which policies and give details below:
Waiver of Subrogation:	YesNo
If yes, specify which policies and give details below:
30 Days Notice of Cancellation:	YesNo

Certificate Of Insurance Request Form

Additional Comments Please give any additional instructions you feel appropriate for this certificate.
Comments: