Request a Certificate of Insurance

Lighthouse Insurance believes it should be easy to do business with us, which is why we offer our business clients the option of requesting a certificate of insurance whenever and wherever it’s convenient for you. Fill out the form below, and a business insurance specialist will be in touch with you shortly.

Please Choose One:
Please check those that apply:
- Written Contract
- No Written Contract
- Current Policy Term
Certificate Holder Needs Additional Insured Status
- Yes
- No
(Additional premium may apply)
If additional insured status is requested, is there a written contract?
- Yes
- No
Attach document with additional requirements (optional)
Prepare a Certificate of Insurance to the following
Insured Name
Personal Business
Insured Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insured Email
Insured Phone Number
Where we can reach you during the day
Certificate Holder's Name*
Personal Business
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Description of Operations (optional)
Auto Certificates
If you require an Auto Certificate, please fill out the below section.
Vehicle Year*
Vehicle Make*
Vehicle Model*
Vehicle VIN#*
For the following vehicles:*
Return To
Please enter email, fax number or mailing address of recipient
Email*
Fax Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Email
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Request a Certificate of Insurance

Prepare a Certificate of Insurance to the following

Auto Certificates

Return To

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