Anderson Insurance Client Services

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ANDERSON INSURANCE CLIENT SERVICES

Order your Certificates of Insurance Online 24/7! Filling out this form will send a direct email to a commercial lines customer service representative who will send you a confirmation of receipt via email, and complete your certificate request in a timely and professional manner.

CLIENT INFORMATION

Client's Name:

Your Full Name:

Company Name: (Company REQUESTING Certificate)

Company Mailing Address:

7 EASY CERTIFICATE INSTRUCTION QUESTIONS...

	If you are doing any of the types of work on this list, please indicate:

	Briefly describe the type of work:
	Provide a BRIEF description here.

	Provide the job location:
	In the absence of an address, provide cross streets and the city.

	Cost & Length of Job:

	Does anyone need to be named additional insured?
		If yes, give name and address.

	Is "Endeavor to.." and "But failure to mail.." need to be lined out?

	Additional wording or instructions, if any.

CERTIFICATE DELIVERY INSTRUCTIONS

Does certificate need to be faxed?

Fax the certificate to:

Fax the certificate to the attention of:

Fax Number:

Certificate requirements can be confusing, If you are not sure just fill out this form and fax us the requirements at (866) 810-3030.

Anderson Insurance and Investment Agency, Inc.
Minnesota LICENSE #0027119
Shaun J. Irwin, C.P.C.U., R.P.L.U
312 Central Avenue S.E., Minneapolis, Minnesota 55414-1064
Phone: (866) 710-3030 TOLL FREE
Fax: (866) 810-3030 TOLL FREE
Email: shaunirwin@andersonagencyins.com

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