To request a certificate, please complete the entire form below.

Your Information

Named Insured

Your Full Name

Phone

Fax

Email

Coverage Requested
Waiver of Subrogation Umbrella Auto
General Liability All Lines Property
Employee Benefits Professional Liability  


Certificate Holder
(Who is asking for proof of insurance)

Is this a new holder?
Yes No

Holder's Company Name

Holder's Contact

Address

City
  		State
  		Zip

Phone

Holder Listed as Additional Insured?
Yes No

If yes, please describe

Loss Payee Endorsement requested by client?
Yes No

If yes, what is the lease or loan number?
Type of equipment if applicable?

Project Number and Description
(Please be sure to include operations, locations, and vehicles)

Date Certificate is Needed (mm/dd/yyyy)

Cancellation Notice
(Please list in days)

Special Instructions
The Allen Thomas Group
4081 N. Jefferson Street
Medina, OH 44256
Ph: 440-826-3676 | info@allenthomasgroup.com


Securities offered through Sigma Financial Corporation, member FINRA / SIPC. Investment advisory services offered through Sigma Planning Corporation, a registered investment advisor.

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