Samel/Paramount Insurance Agency :: Request a Certificate of Insurance

Personal service from a professional agency
serving New England for over 65 years!

Request a Certificate of Insurance

This page is intended for contractors only. If you are looking for assistance with any other business or personal insurance needs, please contact us. To request a commercial Certificate of Insurance, please fill out the following form:
Account Number	(if you know it)
Date
Insured's Name
Email Address	required
Name of Certificate Holder
Street Address
City, State & ZIP Code
Job Name/Property Name
Location Address
Special Requirements	Yes No
Certificate Holder "Named Additional Insured"	(ISO Form CO 20 10 11 85)
	30 Day Notice of Cancellation 10 Day Notice of Cancellation Special Wording for Banks: "Their Successors and/or Assigns, ATIMA" ISO Form CG 25 03 11 85 (Separate Aggregate Limit per Project)
Additional Requirements
Special Forms to Attach
Additional Comments