Columbian Insurance Agency

Certificate of Insurance Request

If you are a client of Columbian Agency, you may also request your certificate directly with the agency by logging into Client Services above.
Named Insured
Account Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Requested by:
enter your name
Requestors Email Address:
Requestors Phone Number:
Requestors Fax Number:
Certificate Holder
Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Delivery Information
Delivery Method (Please select one) Fax  Email
Email Address:
Fax Number:
Attention to:
Required Coverage Information
(*) please provide description below
  Limit Required: Add'l Insured: Add'l Information
General Liability: (*)
Automobile Liability: (*)
Automobile Physical Damage: (*)
Propert/Contents: (*)
Equipment: (*)
Umbrella: (*)
Workers Compensation:
Other:
Required Coverage information description
Please enter description from selections above.
Description:
Additional Insured:
please select one
GL  Auto
Describe Interest of Certificate Holder
Select Interest Type Loss Payee  Mortgagee
Special Instructions:
Please Select: Primary  Non-Contributory
Waiver of Subrogation: GL  Auto  Workers' Comp
Cancellation: Yes  No
If Cancellation (please specify):
Other (please specify):
Certificate Information
Description of Operations:
Insuror Letter:
Cancellation Days:
Additional Information
Your Email Address:
Additional Notes:
* = Required Field
Attention: Please FAX or EMAIL a copy of the contract and insurance requirments to our office. - Select OUR AGENCY TEAM under ABOUT US on our menu for the appropriate contact information.


WELCOME

Borrowing our name from the 1893 Columbian Exposition that celebrated innovation in America, we’ve built our firm by developing innovative insurance and risk management solutions for our clients. Finding effective solutions requires knowledge, commitment and perseverance. It all starts by doing things the right way—from the beginning.

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