Phone: (262)248-5555

Glass Insurance Center

 
 
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Certificate Request Form

Please fill out the following Certificate of Insurance request form. Please note that coverage changes will NOT be in effect until you receive confirmation from our office.

*Required Fields

Insured Information
*Name
Address
City
State
Zip
*Phone
*E-Mail

Certificate Holder
*Name
*Address
*City
*State
*Zip

Additional Insured and/or Loss Payee Name and Address

(if any)
Add as (please choose one)
Name
Address
City
State
Zip

Does Certificate Apply To Leased Or Rented Equipment Or Autos?

If Yes, Please Describe Item.

Description of Leased or Rented Equipment or Auto

What is the Value and Duration of Lease for the Item Above?
Value
Duration of Lease

Project Name & Address

(Only Needed If Additional Insured Applies)

Other Information or Special Instructions

Note: Coverage changes will NOT be in effect until you receive confirmation from our office.

 

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