Process a COL (v101)

Process a COL

Certificate of Liability (Smart PDF)
Producer & Agency Info:
Full Name of Agency/Organization*
Enter exactly as it appears on the agency license
Agency Address (Line 1)
Agency Address (Line 2)
Agency Phone Number*
Agency Email*
LSI address (Street Address)
LSI address (City, State, Zip)
LSI Agency Phone Number*
LSI Agency Email*
HRC address (Street Address)
HRC address (City, State, Zip)
HRC Agency Phone Number*
HRC Agency Email*
Rouland address (Street Address)
Rouland address (City, State, Zip)
Rouland Agency Phone Number*
Rouland Agency Email*
Searchlight address (Street Address)
Searchlight address (City, State, Zip)
Searchlight Agency Phone Number*
Searchlight Agency Email*
LA Metro address (Street Address)
LA Metro address (City, State, Zip)
LA Metro Agency Phone Number*
LA Metro Agency Email*
Person completing form (LSI)*
The completed PDF form will be emailed to the email address associated with this person
Person completing form (HRC)*
The completed PDF form will be emailed to the email address associated with this person
Person completing form (Rouland)*
The completed PDF form will be emailed to the email address associated with this person
Person completing form (Searchlight)*
The completed PDF form will be emailed to the email address associated with this person
Person completing form (LA Metro)*
The completed PDF form will be emailed to the email address associated with this person
Contact Name on pdf
For Mapping
Today's Date*

MonthDayYear
Date
COL being issued for*
Did you Bind Coverage. *
NEVER release an COL unless we have confirmation of binding.
STOP: Do not release this COL. You must first bind the policy with the carrier then comeback to complete this COL.
Client Info:
Is the Insured a legal entity such as a LLC or Corporation or are they Individual people/sole proprietor*
Note: All the names will show on the evidence in the named insured area (box)
What is the name of the Business entity. This must match 100% exactly as it appears on the policy*
IMPORTANT: This must match 100% exactly as it appears on the policy declarations
How many named insured will there be in the policy, therefore showing on the COL. (This must match the Policy)*
Note: All the names will show on the evidence in the named insured area (box)
What is the name of the 1st Named Insured*
IMPORTANT: This must match 100% exactly as it appears on the policy declarations
What is the name of the 2nd Named Insured*
IMPORTANT: This must match 100% exactly as it appears on the policy declarations
What is the name of the 3rd Named Insured*
IMPORTANT: This must match 100% exactly as it appears on the policy declarations
What is the name of the 4th Named Insured*
IMPORTANT: This must match 100% exactly as it appears on the policy declarations
Does the named insured use a DBA*
Note: This DBA would be how the business is advertised to the public unless they use the entity name only
What is the name of the DBA.*
IMPORTANT: Make sure to enter the DBA name as it appears on all publications
mapping-Entity and/or DBA name *
Will the DBA need to appear on COI*
Note: This DBA would be how the business is advertised to the public unless they use the entity name only

Email Subject Line Identifier
Commercial General Liability:
Does the client have Commercial General Liability with our agency

YesNo
What is the Policy Number*
mapping- A letter on CGL
Who was Coverage placed with for this CGL policy*
What's the name of the Ins. Carrier providing coverage on CGL policy*
What's the name of the Writing Co on this CGL policy*
Writing Company CGL - Passed Direct*
What's the name of the MGA providing coverage on CGL policy*
What's the name of the Writing Co on this CGL policy*
Writing Company CGL - Passed MGA*
What is the carrier's NAIC number code*
Insurer A
What type of CGL policy is this.

Claims-MadeOccurrence
How will the general aggregate limit apply

Per PolicyPer ProjectPer LocationOther
Will the certificate holder be also an additional insured for this CGL

YesNo
Is there a waiver of Subrogation listed on this policy.

YesNo
What's the effective date of the Policy*

MonthDayYear
Date
What's the expiration date of the Policy*

MonthDayYear
Date
Coverage Limits for Commercial General Liability:
Choose the standard or custom limits for CGL*
Bodily Injury & Property Damage Limit - Each Occurrence*
Damage To Premises Rented To You Limit - Any One Premises*
Medical Expense Limit - Any One Person*
Personal Injury & Advertising Injury Limit - Any One Person or Organization*
General Aggregate Limit*
Products/Completed Operations Aggregate Limit*
Automobile Liability:
Does the client have an Automobile Policy

YesNo
What is the Policy Number for this Commercial Auto
mapping- B letter on Auto
Who was Coverage placed with for this Automobile policy*
What's the name of the Ins. Carrier providing coverage on Auto policy*
What's the name of the Writing Co on this Auto policy*
Writing Company Auto - Passed Direct*
What's the name of the MGA providing coverage on Auto policy*
What's the name of the Writing Co on this Auto policy*
Writing Company Auto - Passed MGA*
What is the carrier's NAIC number code*
Insurer B
Will the certificate holder be also an additional insured for this CGL

YesNo
Is there a waiver of Subrogation listed on this policy.

YesNo
What's the effective date of the Policy*

MonthDayYear
Date
What's the expiration date of the Policy*

MonthDayYear
Date
Coverage Limits for Automobile Liability:
What type of Liability Limit does this policy cover*
What is the combined single limit on the policy*
Bodily Injury (per person)*
Bodily Injury (per accident)*
Property Damage (per accident)*
Check all that applies if this policy have the following symbols.*

Symbol 1 (Any Auto) endorsementSymbol 2 (Owned Autos Only) endorsementSymbol 7 (Scheduled Autos) endorsementSymbol 8 (Hired Autos Only) endorsementSymbol 9 (non-owned autos only) endorsement
Umbrella / Excess Liability:
Does the client have an Umbrella / Excess Liability Policy

YesNo
What is the Policy Number
mapping- C letter on umbrella
Who was Coverage placed with for this Umbrella/Excess Liability policy*
What's the name of the Ins. Carrier providing coverage on Umbrella / Excess Liability policy*
What's the name of the Writing Company on this Umbrella / Excess Liability policy*
Writing Company Umbrella - Passed Direct*
What's the name of the MGA providing coverage on Umbrella / Excess Liability policy*
What's the name of the Writing Company on this Umbrella / Excess Liability policy*
Writing Company Umbrella - Passed MGA*
What is the Insurer carrier's NAIC number code on this Umbrella/Excess Liability policy*
Insurer C
What type of additional liability

Umbrella LiabilityExcess Liability
What type of additional liability is this

Claims-MadeOccurrence
Is there additional Insured

YesNo
Is there a waiver of Subrogation

YesNo
What is the effective date of the Additional liability Policy

MonthDayYear
Date
What is the expiration date of the Additional liability Policy

MonthDayYear
Date
Coverage Limits for Umbrella / Excess Liability:
Each Occurence*
Aggregate*
Workers Compensation and Employers' Liability:
Does the client have a Workers Compensation policy

YesNo
What is the Policy Number for workers compensation
mapping- D letter on workers comp
Who was Coverage placed with for this Workers Compensation policy*
What's the name of the Ins. Carrier providing coverage on Workers Compensation Policy*
What is the name of the Writing Company on this Workers Compensation Policy*
Writing Company Workers Comp - Passed Direct*
What's the name of the MGA providing coverage on Workers Compensation Policy*
What is the name of the Writing Company on this Workers Compensation Policy*
Writing Company Workers Comp - Passed MGA*
What is the Insurance carrier's NAIC number code for this workers' compensation policy*
Insurer D
Any Proprietor/ Partner/ Executive officer/ Member Excluded?

YesNo
How many are excluded
Worker's Comp Y or N
Enter the Full name of the 1st excluded person
Enter the Full name of the 2nd excluded person
Enter the Full name of the 3rd excluded person
Is there a waiver of Subrogation listed on this policy.

YesNo
Text - Excluded Verbiage
What is the effective date of the Workers Comp Policy

MonthDayYear
Date
What is the expiration date of the Workers Comp Policy

MonthDayYear
Date
Coverage Limits for Workers Compensation and Employers' Liability:
How will limits apply*

Per StatueOther
What is the employers' liability per each accident*
What is the employers' liability per employee*
What is the employers' liability per disease - per policy year*
Professional Liability:
Does the client have a Professional Liability policy

YesNo
What is the Policy Number for Professional Liability
mapping- Professional Liability text
mapping- E letter on insured letter
Who was Coverage placed with for this Professional Liability policy*
What's the name of the Ins. Carrier providing coverage on Professional Liability policy*
What is the name of the Writing Company on this Professional Liability policy*
Writing Company Professional Liability - Passed Direct*
What's the name of the MGA providing coverage on Professional Liability policy*
What is the name of the Writing Company on this Professional Liability policy*
Writing Company Professional Liability - Passed MGA*
What is the Insurance carrier's NAIC number code for this Professional Liability policy*
Insurer E
Is there additional Insured

YesNo
Is there a waiver of Subrogation

YesNo
What is the effective date of the Professional Liability Policy

MonthDayYear
Date
What is the expiration date of the Professional Liability Policy

MonthDayYear
Date
Coverage Limits for Professional Liability:
Each Occurrence*
Aggregate*
mapping - Occurrence Text
mapping - Aggregate Text
Remarks:
Would you like to enter any verbiage/language that would appear in the remarks section of the COI*
Description of Operations/ Location /Vehicles (Acord 101, Additional Remarks Schedule, may be attached if more spaces is required) *
Note: Since most lenders/mortgage companies require there be at least 6 months remaining on the Policy, especially for a loan closing transaction. Therefore, the expiration date of the Policy will be extended for another 12 months.

Please remember to bill for the renewal premium when completing the invoice. Since we do not have the actual renewal premium then we simply take the current term premium plus an additional 10%. Any extra premium will simply be refunded to the customer.
Certificate Holder:
Do you have a Certificate Holder that you would like to show on the Acord 25
What is the name of the Certificate Holder*
What is the name of the Certificate Holder continued (line 2)
leave blank if it does not apply
What is the name of the Certificate Holder continued (line 3)
leave blank if it does not apply

Signature
This Name will appear as the Authorized Representative at the bottom of the Acord 25
Represented Agency
This will appear as the Agency at the bottom of the Acord 25
Should be Empty: