Employment Opportunities with Haines & Haines/T.C. Irons

Certificate of Insurance Request Form

To request a Certificate of Insurance, please complete the form below and click the Submit Button.

Certificates are processed and sent by the end of the next business day.

Certificate of Insurance Request Form

Insured Information

Insured's Name (Last, First): , Requester Name: Street Address:
City: State: Zip: Phone Number:

Certificate Holder Information

Certificate Holder: Attention:
Project Name:
Street Address:
City: State: Zip:

Does the Certificate Holder need to be named as an additional insured? Yes No

If yes, what is their interest (e.g., landlord, mortgages, vendor, lose payee, etc...):

Sending Instructions

Select One or More of the Following FAX certificate to CERTIFICATE HOLDER at: FAX certificate to Requestor at:
EMAIL certificate to CERTIFICATE HOLDER at: EMAIL certificate to Requestor at:
Mail Original Certificate Holder (at the address provided above)

Special Instructions

Send Request To: Frances Blum Donna Callihan Melanie Hennessee Kathy Irons Karen Kendra Chris Lehr Al Lusardi Danielle O'Hara Tricia Pelehach Sharon Roitman Jennifer Shaver Angelique Stambouli unknown

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Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process.  We also collect the same information as part of service and update activities.  The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

Policy Coverage and Disclaimer