Request a certificate

Request a Certificate

Date of Request:			Insured's Name:
Contact Name:			Contact Phone:
Contact Fax:			Contact Email:
Relationship to Insured:
NOTE: If you have received written insurance requirements or a contract, please forward a copy with this request to: dsmith@lanelennon.com or phone 386-734-0800 so we may issue the certificates correctly.
Certificate Holder's Name:			Attention:
Address:			City/State/Zip:
Email:
Contact Phone:			Contact Fax:
Does the certificate holder need to be shown as an additional insured?
Does the certificate holder require a Waiver of Subrogation?
Please be advised that we CANNOT send out a certificate of insurance with Certificate Holder added as Additional Insured or if a Waiver of Subrogation is required unless you send us a copy of the Contract Insurance Requirements information. Please send it to dsmith@lanelennon.com; or phone her at (386) 734-0800 ext. 203.
Additional Information: