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or 800-777-8316
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Allen and Lambert Insurance
1760 Bass Road Suite 101
Macon, Georgia 31210
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Phone: 478-474-6468
Fax: 478-474-0116
Toll Free: 800-777-8316
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     REQUEST CERTIFICATE

Request for Certificate of Insurance

Certificate Holder Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
 Fax:  

Recipient Information
First & Last Name:  
Street Address:  
City, State & Zip:  
Telephone:  
 Fax:  
Attention:  
 Job Reference:  

Do you want certificate faxed?  
Policies to Reference:  
Additional Insured:  
If Yes, give details
and which policies:  
Waiver of Subrogation:  
If Yes, give details
and which policies:  
30 Days Notice of Cancellation:  

Any Additional Comments or Instructions?
Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.


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