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Certificates of Liability
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Request for Certificate of Insurance This information will only be provided to the insured or certificate holder.
Receipt of certificate of insurance will indicate processing of your request. If you fail to receive, please call The Murray Insurance Agency at 270-753-4751.
* indicates required information
Insured's Name*
Policy Number*
Effective Date*
Phone Number*
Fax Number
E-Mail*
Certificate Holder Is: (check one)* Additional Insured Mortgagee Loss Payee Holder Only
Certificate Holder Information
Name*
Address*
City * State* Zip*
Fax
Preferred Method of Delivery (choose one) * FAX EMAIL MAIL PICK UP AT AGENCY
Requested By *
Date*
Questions/Comments
Please note that this form is for a request only. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, assume we did not get this request for an insurance quote, and call our office.
I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.
I have read and agree with the above disclaimer (it is mandatory to check box before request can be sent).
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