Secure Certificate Request Form

Your Name:

First	Last

Email Address:

Phone Number:

5 Digit Zip:

Account Holder

Insured Name:

Company Name:

Address:

City

State:

Zip:

Certificate Recipient

Recipient Name:

Recipient Address:

Recipient City

Recipient State:

Recipient Zip:

Recipient Phone:

Recipient Fax:

Recipient Email:

Attention:

Job Reference:

Certificate Information

How Should This Be Sent?

Policies to Reference:

Additional Insured:

If Yes, give details
and which policies:

Waiver of Subrogation:

If Yes, give details
and which policies:

Primary Wording
Endorsement:

Policy Number:

Additional Comments
or Instructions:

Agent Name (Optional):

Website Disclaimer - Review Carefully:

The undersigned client ("You") consents to receive text messages from School Insurance Agency ("The Agency"). As part of this consent, You represent and warrant the following:

The Agency (employees or others on the Agency’s behalf) may send text messages in various formats and with different contents, including but not limited to text messages about insurance policies and other transactions initiated by You or marketing the products and services offered by or through the Agency.

You are the owner or authorized user of the mobile phone number identified through this opt-in process. You will notify us immediately if you are no longer the owner or authorized user of this mobile phone number identified through our opt-in process.

You are solely responsible for any message and data charges associated with such text messages.

If you do not wish to receive text messages from the Agency or others acting on the Agency’s behalf or do not agree to the Terms of Use, you should not submit this form.

To Opt out of receiving text messages from The Agency at any time, send a text with STOP to The Agency, and You will be removed from the opted-in list. Once you have opted out, you must resubmit the opt-in consent form to receive future messages.

The Agency has made its Privacy Policy available to You on its website and will provide You with a hard copy upon request. By submitting this opt-in form, You agree to these Terms of Use.

This is a solicitation for insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voicemail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.