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

We highly recommend Shapiro Insurance Group. We maintain both business and personal policies with this agency and have experienced nothing but positive results. Donna Setaro is a wonderful agent whose knowledge and experience have benefited us numerous times.

— T Ramsundar

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