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Community Association Certificate Request Form


We will provide you with Certificates of General Liability and Property Insurance using the information below. Please allow a 24 to 48 hours for the Certificates of Insurance to be issued. Any questions please contact our office at 845-265-2220 Ext 126.

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Personal Information
First Name
Required
Last Name
Required
Primary Phone Number
Required
E-Mail Address
Required
Community Association
Community Association Name
Required
Reason for Certficate
Required
Unitowner Information
Unit Owner's Name
Required
Unit Number
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Unit Owner's Phone Number
Optional
Mortgagee Information
Mortgagee/Bank Name
Required
Mortgagee/Bank Name Continued
Optional
Loan Number
Optional
ISAOA / ATIMA
Optional
Mortgagee Address
Required
Mortgagee City, State & Zip Code
Required
Closing Date (if applicable)
Optional
/ /
Delivery Method
How shouled we Deliver the Certificate
Required
Email Address
Optional
Fax Number
Optional
Mailing Address
Optional
Mailing Address Line 2
Optional
Additional Information
Optional
If you would like a Unit Owner's Quotation please complete the following additional information.
Additional Personal Information
Unit Owner's Date of Birth
Optional
/ /
Contact Information (if different then certificate request)
Optional
Coverage
Dwelling (Additions and Alterations) Limit
Optional
Personal Property (Contents) Limit
Optional
Loss Assessment Limit
Optional
Scheduled Personal Property (Description and Limit)
Optional
Water Backup Limit
Optional
Deductible
Optional
Personal Liability Limit
Optional
Medical Payments Limit
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Gerelli Insurance Agency, Inc.   |   PO Box 362, Cold Spring, NY 10516   |   (845) 265-2220   |  Fax: (845) 265-4754               Powered by Insurance Website Builder 

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