(503) 668-2524 Sandy, OR

Request Evidence of Insurance

Please fill in the following fields, providing as much information as possible. Please be sure
to include any additional instructions in the box provided.

Your Information

First Name *
Last Name *
Phone Number *
Email *
Your HOA's Name
Vesting (Legal Name on Title)

Property Street Address *
Unit Number
City *
State *
Zip Code *

Delivery Method

Fax to
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Mail to
Name
Address
City
State
Zip Code

Your Lender Information

Lenders Name *
Lender Position *
Street Address *
City *
State *
Zip *
Email
Interest Type *
Loan Number *

Additional Instructions

Insurance products are offered by CCB Insurance Services LLC, not by Clackamas County Bank. CCB Insurance Services LLC is licensed as an insurance agent and acts as agent for insurers. Insurance policies are obligations of the insurers that issue the policies. Insurance products may not be available in all states. Insurance Products: • Are NOT Deposits • Are NOT FDIC-Insured • Are NOT Insured By Any Federal Government Agency • Have NO Bank Guarantee • May Go Down In Value. In the case of an application for credit in connection with which an insurance product is solicited, offered, or sold, the bank may not condition an extension of credit on either the consumer’s purchase of an insurance product from the Agency, or the consumer’s agreement not to obtain insurance from another entity.