Welcome to the online home of Landmark Insurance Associates!  I'm glad you stopped by. We have created this website as a way to provide you with a convenient way to obtain insurance service and information. Please browse around the site to become familiar with what we have to offer. Let me know what we can do to serve you.

Michael D. Wright
President
REQUEST FOR CERTIFICATE OF INSURANCE
 
Organization Name:

 
Address:
 
City:
 		             State:   
 		 ZIP:
 
Requested By:
 		   Email Address:
 
Phone Number:
 		  Fax Number:
     
CERTIFICATE HOLDER  
     
Name:
 
Address:
 
City:
 		             State:   
 		 ZIP:
 
Attn:
 		   Fax Number:
 
CERTIFICATE HOLDER TO BE NAMED  
   
Additional Insured YES    NO
Loss Payee YES    NO
Evidence of Property Damage YES    NO
Landlord YES    NO
Mortgagee YES    NO
   
Reason for Certificate:
(description of activity, or property address):

Dates, Amount of People, Equipment:
Special instructions:

Please make sure all form fields have been completed before submitting.

    

©2007 Landmark Insurance Associates

Certificate of Insurance
  


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