Request Certificate of Insurance

Name: Fallon Insurance Agency
Price range: $$

Request Certificate of InsuranceGravity Certs2026-04-29T07:36:38-05:00

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Company

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Certificate of Insurance Request Form

Please submit Certificate of Insurance (COI) requests 3–5 business days in advance. Our team will do our best to process your request as quickly as possible.

Certificates will be emailed to the insured and certificate holder. Incomplete information may cause delays.

Policy Holder Information

Your Business Name*

Email*

Your Full Name*

First Last

Phone

Certificate Holder Information

Certificate Holder Business Name*

Certificate Holder Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address

Please provide the email address where the COI should be sent.

Additional Email Address

If needed

Are you requesting COI Holder to be named as Additional Insured?

Yes

Best Describes COI Holder

Additional Information

Upload COI Requirements

Please upload Sample COI or Contract for additional requirements, if necessary

Drop files here or

Max. file size: 20 MB.

Additional Language

If required

Urgency of Request

Normal

Urgent

Section Break

Certificate Details

Interest of Certificate Holder

Evidence of Insurance Only

Additional Insured

Waiver of Subrogation

Primary / Non-Contributory

Ongoing with Completed Operations

See attached requirements from Certificate Holder

Project Details

Project Name

Project Start Date

Approximate Project Completion Date

Estimated Cost of Project

Type of Building

What is the address of the Job/Project Location?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For "Various Locations" - provide city(s) or county(s)

Description of work to be performed

Waiver of Subrogation for:

General Liability

Auto

Workers Compensation

Job Dates

Job Payroll

Job Description

Please review your information prior to submitting this request for accuracy. If you need to make changes prior to submitting this request, click the Previous button to make your changes.

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Insurance Options

We take a consultative approach to protecting households and businesses – reviewing exposures, analyzing policy structures, and guiding clients toward coverage that delivers both confidence and value.

Agent License: #40902670

Oshkosh WI Office

2450 Witzel Avenue Suite 101

Oshkosh, Wisconsin 54904

Phone: 920-312-7877

View Office Information ›

Office Hours

Mon-Fri 9:00am – 5:00pm

Sat, Sun, and evenings by appointment only, or click here to start your insurance quote online.

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Resources

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Proudly offering insurance services, home insurance, auto insurance, flood insurance, life insurance, commercial insurance for businesses, and homeowners association insurance (HOAs) in all of Illinois, Indiana, Iowa, Minnesota, and Wisconsin, including Appleton, Ashwaubenon, Beloit, Brookfield, De Pere, Eau Claire, Fond du Lac, Grand Chute, Green Bay, Janesville, Kenosha, La Crosse, Madison, Menomonee, Mequon, Milwaukee, Muskego, Neenah, New Berlin, Oak Creek, Oconomowoc, Onalaska, Oshkosh, Pleasant Prairie, Racine, Sheboygan, South Milwaukee, Stevens Point, Sun Prairie, Waukesha, Wausau, Wauwatosa, West Allis, West Bend, Wisconsin Rapids, and the surrounding areas. View all service areas.

DISCLAIMER: Informational statements regarding insurance coverage are for general description purposes only. These statements do not amend, modify or supplement any insurance policy. Read your policy or consult with your agent for details. Your eligibility for particular products and services is subject to final underwriting and acceptance by the insurance company providing such products or services. This website does not make any representations that coverage does or does not exist for any particular claim or loss, or type of claim or loss, under any policy. Be sure to read the policy, including all endorsements, or prospectus, if applicable.

Insurance Fraud Statement

Fraud is a crime

If your application contains purposefully misleading, absent, or inaccurate information, you could be charged with fraud. Your insurance carrier could potentially void your policy, or you could face civil or criminal charges or penalties.

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime.

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