Florida Alliance Insurance -- Certificate of Insurance Request Form

813-661-7200
800-606-7211
www.floridainsurancequotes.us
www.floridaallianceinsurance.com

Certificate of Insurance Request Form
This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible to receive an accurate certificate. This information will be kept strictly confidential and will be used for these purposes only.

This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

Insured Information

Insured Making Request: Date:

Address:

City: State: Zip:

Phone: Fax:

Email Address:

Recipient Information

Please issue Certificate of Insurance to the following:

Name:

Address:

City: State: Zip:

Attention:

Job Reference:

Do you want Certificate faxed?: Yes No Fax #:

Certificate Information

Policies to Reference*:

Auto
Umbrella General Liability
Equipment Workers' Comp.
Builders Risk

*Unless you specify differently, Auto, General Liability and Workers' Comp will be
the only policies indicated on Certificate (when applicable)

Additional Insured: Yes No If YES, Specify which policies and give details below:

Waiver of Subrogation: Yes No If YES, Specify which policies and give details below:

30 days Notice of Cancellation: Yes No

Special Instructions

Please give any special instructions you feel appropriate for this certificate.

Please click on the "Submit Request" button to send your Certificate request.
One of our representatives will respond to your submission as soon as possible.

This Certificate of Insurance Request Form Copyright © 1999 - by ENHANCED Web Services

Copyright © Florida Alliance - All Rights Reserved