Certificate Request Form

WELCOME TO OUR INSURANCE

CERTIFICATE REQUEST PORTAL

THROUGH THIS ELECTRONIC FORM YOU WILL BE ABLE TO SUBMIT A REQUEST FOR A CERTIFICATE OF INSURANCE. PLEASE NOTE: THAT INSURANCE COVERAGE CANNOT BE BOUND OR CHANGED VIA SUBMISSION OF THIS ONLINE FORM. INSURANCE COVERAGE DOES NOT GO INTO EFFECT UNTIL CONFIRMED AND APPROVED BY THE INSURANCE CARRIER(S).

ALL COVERAGES ARE SUBJECT TO THE TERMS, CONDITIONS, AND EXCLUSIONS OF THE ACTUAL POLICY ISSUED, AND NOT ALL POLICIES OR COVERAGES ARE AVAILABLE IN EVERY STATE.

IN ORDER TO PROTECT YOUR PRIVACY, PLEASE DO NOT SEND US ANY CONFIDENTIAL OR PERSONAL INFORMATION BY THIS ELECTRONIC FORM, EMAIL OR FAX, INSTEAD DISCUSS SUCH INFORMATION WITH ONE OF OUR AGENTS BY PHONE OR IN PERSON

PLEASE CONTACT OUR OFFICE AT 678-904-1642 EMAIL AT SUPPORT@MYATLAGENCY.COM IF YOU HAVE QUESTIONS ON AN SPECIFIC COVERAGE, FORMS & POLICY LIMITS.

THANK YOU!
ATL INSURANCE
THE CERTIFICATE OF INSURANCE IT'S REQUESTED BY: *

CLIENT / POLICYHOLDER. CERTIFICATE HOLDER. INSURANCE SERVICE PROVIDER. THIRD PARTY (ADDITIONAL INSURED).
BY CLICKING "AGREE & CONTINUE" I CERTIFY THAT:
- ALL INFORMATION THAT I WILL PROVIDE IS CORRECT AND TO THE BEST OF MY KNOWLEDGE.
- I UNDERSTAND THAT NO COVERAGE IS BOUND ON ANY INSURANCE COVERAGE UNTIL CONFIRMED IN WRITING BY OUR AGENCY IF ENDORSEMENTS AND/OR CHANGES ARE REQUIRED.
- ENDORSEMENTS, FORMS AND/OR SPECIAL WORDING MAY REQUIRE ADDITIONAL PROCESSING TIME AND/OR FEE.
- CORRECTLY COMPLETED CERTIFICATE REQUESTS WILL BE PROCESSED IN A SHORTER TIME.

1. CLIENT / POLICY HOLDER INFORMATION:

Fields marked (*) are mandatory.
CLIENT / POLICY HOLDER NAME *
INCLUDE D.B.A NAME IF KNOWN
POLICY NUMBER *
AT LEAST ONE POLICY NUMBER IF THERE ARE MORE THAN ONE
POLICY HOLDER PHONE NUMBER *
AREA CODE + NUMBER
2. CERTIFICATE HOLDER INFORMATION

COMPANY REQUESTING TO VERIFY COVERAGE(S)
CERTIFICATE HOLDER EMAIL ADDRESS *
WHERE THE CERTIFICATE WILL BE SENT.
CERTIFICATE HOLDER NAME *
AS IT SHOULD READ ON THE CERTIFICATE
CERTIFICATE HOLDERS ADDRESS *

Street Address

Street Address Line 2

City State

Zip Code
CERTIFICATE HOLDER CONTACT NAME *

First Name Last Name
CERTIFICATE HOLDER PHONE NUMBER

ADDITIONAL INSURANCE ENDORSEMENT FORM

CGL FORM GC 2010
PREMIUM MAYBE AFFCTED BY THE ENDORSEMTNS AND SPECIAL FORMS
DOES THE CERTIFICATE HOLDER NEEDS TO BE LISTED AS AN ADDITIONAL INSURED? *

No Yes

ADDITIONAL INSURANCE ENDORSEMENT FORM