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Exchange Insurance Agency Inc.
718 Central, PO Box 218
St. Paul, Kansas 66771
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Altamont Office

Phone: 620-449-2202
Fax: 620-449-2205
Toll Free: 800-697-1656
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REQUEST CERTIFICATE

Request for Certificate of Insurance

Certificate Holder Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
 Fax:  

Recipient Information
First & Last Name:  
Street Address:  
City, State & Zip:  
Telephone:  
 Fax:  
Attention:  
 Job Reference:  

Do you want certificate faxed?  
Policies to Reference:  
Additional Insured:  
If Yes, give details
and which policies:  
Waiver of Subrogation:  
If Yes, give details
and which policies:  
30 Days Notice of Cancellation:  

Any Additional Comments or Instructions?
Note: By submitting this form you understand that no coverage is bound until you receive written notice. 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.


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