Gallina and Sons - Association Certificate Request Form 2.0

Reason for Request *
Requestor's Name: *
Company:
Daytime Phone Number: *
Email Address: *
If applicable the certificate will contain:
- Association Name
- Property Address
- Number of Units Covered
- Minimum number of days for cancellation
- Coverage Included in policies:
  - Co-Insurance
  - Boiler & Machinery/Equipment Breakdown
  - Building Ordinance or Law
  - Inflation Guard
  - Severability of Interestes/Separation of Insureds
  - Managing agent rider
- Borrower Name(s)
- Loan Number
- Mortgagee Information
- Does the community policy cover the interior (walls-in)
- Does the community policy cover improvements and betterments
Association Name: *
Unit Owner's Information
Name and Address
Certificate Holder's Information (Mortgagee Address)
Name, Address, Loan#
Comments or Special Conditions
Payment does not submit your request. Once payment is completed please input invoice number below and click the Submit button.
Receipt Number *
Should be Empty: