Insuring Chicago and All of IL, IN, and WI
N Western Avenue (773) 262-9090

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Home / Policy Service Center / Certificate of Insurance Request

Certificate of Insurance Request

You have the option of requesting Certificates of Insurance on the following electronic form. It is important to include as much information as possible. We will review your request, contact you if further information is required, and then send the certificate of insurance to the appropriate party(s).

General Information
Name of Insured:
Name or Company of Certificate Holder:
Job Reference No.:
Address of Holder:
Street Address Address Line 2 City State ZIP Code
Holder Phone:
Holder Fax:
Your Name:*
Contact Email Address:*
Handling Method:
- Fax
- Email
Required Coverages
Please provide copy of insurance requirements of contract:
- Auto
- Umbrella
- General Liability
- Equipment
- Workers' Compensation
- Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
- Yes
- No
Need Endorsements for Primary Wording:
- Yes
- No
Loss Payee:
- Yes
- No
Mortgagee:
- Yes
- No
Additional Insured:
- Yes
- No
Comments or Other Instructions
Attach File
Please attach written request(s) and/or contracts received, if any.
Name
This field is for validation purposes and should be left unchanged.

August 21st, 2011 by Associated Services Insurance Agency

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N WESTERN AVENUE

Associated Services Insurance Agency
- 6300 N Western Avenue
- Chicago, Illinois 60659
Phone: (773) 262-9090
Fax: (773) 856-0656

Office Hours

Mon – Fri: 9:30 AM to 5:30 PM
Sat: 12 PM to 5:30 PM
Sun: Closed

Associated Services Insurance Agency provides Car, Home, Business, Workers Compensation, Commercial Auto, Garage, Dump Truck Insurance, Ridesharing Insurance, Uber Insurance, Lyft Insurance, Condominium Building Insurance, and Special Events Insurance to all of Illinois, Indiana, and Wisconsin, including Chicago, Des Plaines, Skokie, Aurora, Schaumburg, Rockford, Joliet, Lombard, Cicero, and Naperville.

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Insuring Chicago and All of IL, IN, and WIN Western Avenue (773) 262-9090

Certificate of Insurance Request

General Information

Required Coverages

Comments or Other Instructions

Attach File