Request a Certificate of Insurance

Use this form to request a certificate of insurance. Please allow 24 hours for request to be completed.

Request Certificate of Insurance

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<form-template>
	<fields>
		<field required="true" type="date" name="date" label="Date"/>
		<field required="true" type="text" name="policyholder-name" placeholder="Policyholder Name*" label="Policyholder Name"/>
		<field type="text" name="business-name" placeholder="Business Name" label="Business Name"/>
		<field required="true" type="text" name="address" placeholder="Address*" label="Address"/>
		<field required="true" type="text" name="city" placeholder="City*" label="City"/>
		<field required="true" type="text" name="state" placeholder="State*" label="State"/>
		<field required="true" type="text" name="zip-code" placeholder="Zip Code*" label="Zip Code"/>
		<field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/>
		<field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/>
		<field required="true" type="select" name="method-of-receipt" label="Please send Certificate of Insurance Via:">
			<option selected="true" value="Select One">Select One</option>
			<option value="Email">Email</option>
			<option value="Fax">Fax</option>
			<option value="USPS Mail">USPS Mail</option>
		</field>
		<field required="true" type="text" name="certificate-holder-name" placeholder="Certificate Holder Name*" label="Certificate Holder Name"/>
		<field required="true" type="text" name="certificate-holder-address" placeholder="Certificate Holder Address*" label="Certificate Holder Address"/>
		<field required="true" type="text" name="certificate-holder-city" placeholder="Certificate Holder City*" label="Certificate Holder City"/>
		<field required="true" type="text" name="certificate-holder-state" placeholder="Certificate Holder State*" label="Certificate Holder State"/>
		<field required="true" type="text" name="certificate-holder-zip-code" placeholder="Certificate Holder Zip Code*" label="Certificate Holder Zip Code"/>
		<field type="text" name="certificate-holder-phone-number" placeholder="Certificate Holder Phone Number" label="Certificate Holder Phone Number"/>
		<field type="text" name="certificate-holder-email-address" placeholder="Certificate Holder Email Address" label="Certificate Holder Email Address"/>
		<field type="text" name="certificate-holder-fax-number" placeholder="Certificate Holder Fax Number" label="Certificate Holder Fax Number"/>
	</fields>
</form-template>

Call Today. 877-858-8833

I left a bad review for this company a couple of weeks ago by mistake. This is not the bad insurance company that I meant to leave the bad review. I want to apologize to Shapiro Insurance group if I caused a lost of business for my mistake. Mr. Shapiro's company is the company that I use for my auto insurance needs. The customer service his staff provides is second to none. Mr. Shapiro's staff always will go above and beyond to insure their customers are getting the best possible coverage and quotes. Thank you Mr. Shapiro and I truly apologize for mistaking a world class company like yours for an inadequate company that I thought I was leaving the negative review. Please inform your staff that I truly was mistaken.

— John B.

	9313 Old Kings Rd S, Jacksonville, Florida 32257
	800.563.5467
	info@insuresig.com