Larry E. Palmer Insurance Agency  
 
Agents & Brokers | Contact | Order a Certificate
 
 
 
REQUEST FOR CERTIFICATE OF INSURANCE

Your Business Name:

Your Email Address:
Certificate goes to:

Name:

Address:

City:

State:
    		 ZIP:
     		FAX Number:
If this certificate is for a vehicle, please provide the vehicle information.
Year:
     		Make:
     		Model:
Cost new:
     		GVW:
Vehicle Identification Number:
Should we add them as "additional insured"? Yes    No
Should we add them as "loss payee"? Yes    No
Is this certificate for a specific project?
The name of the Project 		Yes    No
Is this certificate for other reasons? Yes    No
Reason for certificate
  Co-Owner of Insured Premises   Owners / Lessees of Buildings
  Controlling Interest   Engineers, Architects, Surveyors
  Lessor of Leased equipment   Contractors
  Managers or Lessors of Premises   Designated Organization
  Mortgagee, Assignee, receiver   Designated Person
  Leased Land   State of Political Organization
  Government interest   Vendors
Other:
Home | Contact