Cameron Insurance

<%@LANGUAGE="JAVASCRIPT" CODEPAGE="1252"%> Cameron Insurance

This Certificate of Insurance Request Form is for existing clients who hold commercial policies. Please provide as much information as possible to receive an accurate certificate.

Insured Information
Person Making Request *:
Business Name:
Email:*
Address:
City:
State:
Zip Code:
Daytime Phone:
Cell Phone:
Fax:

Recipient Information - Issue Certificate of Insurance to the following:
Business Name *:
Address *:
City *:
State *:
Zip Code *:
Attention:
Phone:
Job Reference:
Do you want certificate faxed?	Yes No
Fax:

Certificate Information
Policies to Reference:	General Liability Auto Garage Excess/Umbrella Worker's Compensation Other
Additional Insured (may incur fees)	Yes (If yes, please provide details in Special Instructions area below.) No
Loss Payee	Yes (If yes, please provide details in Special Instructions area below.) No
Mortgagee	Yes (If yes, please provide details in Special Instructions area below.) No
Waiver of Subrogation (may incur fees)	Yes (If yes, please provide details in Special Instructions area below.) No
30 Days Notice of Cancellation	Yes No
Special Instructions
Please give any special instructions you feel appropriate for this certificate. To help insure the accuracy of your Insurance Certificate, please Fax to 336-896-0776 any insurance requirements you may have received from the Job Owner, Project Manager or General Contractor with this Certificate Request.

“I have been a customer of Cameron Insurance for several years. I have always received exceptional service from my agent Barry Zimmerman. He takes care of our vehicles and home owners insurance. He does a great job of looking out for us in making sure we get the best rates we can receive. Whenever I have a question or problem come up, he gets back with me right away and has the answer or solution to the problem. We appreciate the trust and help that we have gotten over the years and would recommend Cameron Insurance to anyone looking for a company that will put your best interests first.”

Junie Troxell
Quality Oil Company