Certificate of Insurance Request

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.
Email
This field is for validation purposes and should be left unchanged.

Insurance Quotes

Name*
Email*
Phone (Optional)
Select Type of Insurance*
Comments
This field is for validation purposes and should be left unchanged.

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Clay & Land Insurance

866 Ridgeway Loop Road
Memphis, Tennessee 38120

Phone: (901) 767-3600

Mon-Fri: 8:00am-4:30pm
Sat-Sun: Closed

Clay & Land Insurance Provides Auto, Homeowners, Aviation, Business, Life/Health, and Employee Benefits to All of Tennessee, Including Memphis, TN; Germantown, TN; Cordova, TN; Collierville, TN; Bartlett, TN; Jackson, TN; Olive Branch, MS; Southaven, MS; West Memphis, AR; and Lakeland, TN.

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Certificate of Insurance Request

General Information

Required Coverages

Comments or Other Instructions

Attach File