Certificates

Certificate of Insurance Request

Disclaimer: Insurance transactions are NOT effective without acknowledgement
from a Benton Insurance Agency Representative.
*

Certificates issued in 24 hours or less! We will issue all Certificates of Insurance and Additional Insured endorsements that do not require insurance company approval in 24 hours or less. If you are a new client of Benton Insurance Agency, we will issue your Certificate within 24 hours of receiving the policy number.
*Your Company:
*Your Email Address
_______________________________________________________________________________


*Company Name / Certificate Holder:
 
*Address:
 
*City
 
*State
CA
 
*Zip Code:
 
 Attention:
 
  Phone:
 
  Fax:
 
 Email Address:
 
 Job Name/Number:
 
*Job Description & Job Address:
 
*Certificate holder requires
  certificate(s) showing coverage for:
General Liability
Automobile Liability
Workers' compensation/ Employer's Liability
Other:
 


 
  Special Requirements:
  (charges may apply)
Additional Insured Endorsement
Primary Wording
Cross out "endeavor to" and "but failure to mail..." in cancellation section of ACORD form
Waiver of Subrogation
Other: