Certificate Request
Please complete the form below. We will contact you for any additional information required to complete your request. Please note that no changes to your policy will take effect until you receive a confirmation from us.

Note that any additional insured, mortgagee or loss payee constitutes a change to your policy.

Please note that fields with an asterisks(*) are required.
  I. Please identify yourself
Your name* 
Insured* 
Insured shown  on certificate* 
Phone*  
Cell  
Fax ()
Email* 
 
  II. Certificate Holder
Name to appear* 
Address* 
City* 
State*  Zip Code -
Phone*  
Fax  
Email 
Check all that  apply Additional insured  Mortgagee
 Loss payee
If add'tl insured,  reason added 
 
  III. First additional interest
Name to appear 
Address 
City 
State  Zip Code -
Phone  
Fax  
Email 
Check all that  apply Additional insured  Mortgagee  
 Loss payee
If add'tl insured,  reason added 
 
  IV. Second additional interest
Name to appear 
Address 
City 
State  Zip Code - 
Phone  
Fax  
Email 
Check all that  apply Additional insured  Mortgagee  
 Loss payee
If add'tl insured  reason added 
 
  V. Indicate specific property this applies to
Vehicle 
Equipment 
Property location 
Job 
Other 
 
  VI. Policies to be shown
Policies to be  shown General LiabilityAutomobile  
 Umbrella            Workers Compensation
 Property             All Policies
 
 
  VII. Document Deliveries
Deliver to* 
Deliver by* 
 
  VIII. Special Instructions
I understand that no changes to my policy will take effect until you review this request and I receive a confirmation that coverage changes are in effect.
Coverage Inquiry:
Personal Insurance
Commercial Insurance
Life/Health/LTC

Client Service Requests:
Certificate of Insurance
Vehicle Change
Home/Condo/Co-op
Business Insurance
General Policy Request
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Tel: 1-(212)-964-6190    Email: info@ssfinsurance.com
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