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Business Certificate Request Form


Use this form to request a certificate of insurance for individuals and businesses currently insured by this agency. The certificate will be sent promptly in the manor requested. This is no charge for this service.

Requester's Information
We must receive this accurate information to complete your request.
First Name
Required
Last Name
Required
Your Company's Name
Required
Daytime Phone Number
Required
E-Mail Address
Required
Last four digits of your Social Security Number
Required
Type of Certificate to Be Issued
Please select all that apply
Certificate should contain information about ...
Optional



Certificate Recipient Information
Tell us to whom the certificate should be sent and how to send it
Send Certificate to the Attention of ...
Required
Company's Name (If Applicable)
Optional
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Phone Number
Optional
Fax Number
Optional
E-Mail Address
Optional
Preferred Method of Delivery
Required
Comments or Special Conditions
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

© 2011 Gallina and Sons Insurance