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Certificate Of Insurance Request Form

You may use the form below to submit a request for a Certificate of Insurance directly to our agency. We will contact you shortly after receiving the request. This feature is only for existing clients who are commercial policy holders.

Insured Information
InsuredMakingRequest:
Address:
City:
State:
Zip:
Home Phone:
FAX:
E-Mail*:
Date:


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


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


*Required

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

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