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"Request Insurance Certificate" Online Order Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
Phone (REQUIRED):
Fax: (Optional)

Policy & Service Details (You Must Complete ALL Information Below)
Your Policy Number:


Which do you need?	Certificate of Insurance ONLY -or- Certificate of Insurance WITH Additional Insured Endorsement


Name and Address of Additional Insured:

What is this party's insurable interest to you as named insured (i.e., landlord, permit, for job, etc.)

What is the Additional Insured's relationship to job being performed? (i.e. Owner, managing agent, lessor, general contractor, etc.)

Give complete description of job, and job location:

Describe Job cost, and job duration:

Please contact me for service via:	Fax E-Mail Regular Mail Please Call Me!

Thank you for filling out this form COMPLETELY!
We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.
Yes, Please Service My Account. I Understand that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY.

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For Insurance Information contact the Short Insurance Group at:
www.shortinsurancegroup.com Mailing Address: PO Box 70696 Albany, GA 31708
Office Address: 1579 U.S. Hwy. 19 South Leesburg, GA 31763
E-Mail Questions or Service Needs at: service@shortinsurancegroup.com
Please Contact Us At Our Toll Free Phone Number: 888-883-2928
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