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Lakeland:
(901) 867-7283
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Covington:
(901) 475-7283
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Home
>
Policy Service Center
>
Certificate of Insurance Request
General Information
Name of Insured:
Name or Company of Certificate Holder:
Job Reference No.:
Address of Holder:
Street Address
Address Line 2
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Holder Phone:
Holder Fax:
Your Name:
*
Contact Email Address:
*
Handling Method:
Fax
Email
Required Coverages
Please provide copy of insurance requirements of contract:
Auto
Umbrella
General Liability
Equipment
Workers' Compensation
Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
Yes
No
Need Endorsements for Primary Wording:
Yes
No
Loss Payee:
Yes
No
Mortgagee:
Yes
No
Additional Insured:
Yes
No
Comments or Other Instructions
Attach File
Please attach written request(s) and/or contracts received, if any.
Max. file size: 59 MB.
Email
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