Certificate of Insurance Request

Thank you for your interest in Legere Insurance Agency.
Please enter the following information so we can respond to your request quickly and efficiently. Fields followed by an asterisk(*) are required information.
Note: We are licensed to sell insurance only in Massachusetts.

Date: *

Your Company:

Company Name: *
Your Name: *
Street: *
City: *
State: *
Zip Code: *
Email Address: *
Phone: *		Home    Business    Cell

Best way to contact you: *

Email: or Phone:   Time: Choose Time Mornings Afternoons Early Evenings

Certificate Holder: *
(Company requesting Certificate of Insurance from you)

Company Name:
Address:
City:
State:
Zip:

Type of Insurance (check all that apply): *

		General Liability
		Automobile Liability
		Umbrella/Excess Liability
		Workers Compensation
		Property
		Other

Is any party requesting to be an "Additional Insured"? *

Yes    No

If yes:
Company Name:
Address:
City:
State:
Zip:

Please describe the operation, location
and any special requests:
How would like the Certificate to be sent? *

Fax:
Postal Mail:
Other: