Cooper Insurance & Associates

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	What changes are made to your policy once the regulatory filings for your authority are issued?

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Forms

Get a Quote
Certificate of Insurance Request
Report a Claim
Driver Request Form
Request Information

Please fill out the information below in order to receive your certificate. Remember, the more information we obtain from you the faster we can process your request and you receive your certificate. Thank you!

*Signifies a required field below

DATE:

TIME:

INSURED'S NAME:

INSURED'S D/B/A:

INSURED'S ADDRESS:

Street:	City:	State:	Zip:

*NAME OF PERSON:

(Name of person requesting certificate)

NAME OF COMPANY:

(Name of company where Certificate is to be sent)

TO WHOSE ATTENTION:

ADDRESS:

Street:	City:	State:	Zip:

*PHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

Please complete the following if additional interests are applicable:

ADDITIONAL INSURED:

Interests:	Other:

LOSS PAYEE/LEINHOLDER:

Year:	Make:	VIN#:

(Please indicate unit - include year, make, and 17 digit VIN#)

**Only units that have already been added to your policy can be listed! If you need to add
a unit, please contact our office by phone at (770)389-0089 or fax at (770)389-3819. Thank you!

810 Rock Quarry Road, Stockbridge, GA 30281 (770)389-0089