Insurance Certificate Request Form

1

Policy Holder's Name and DBA* This field is required.ex: John Smith, ABC Company, Inc.

Name of Insured (YOUR business)

2

Your Policy Number

3

Your E-mail Address* This field is required.Example: myname@example.com

4

Phone Number* This field is required.I agree to be contacted by Edge Insurance Agency LLC via call, email, and text. To opt-out, you can reply 'stop' at any time or click the unsubscribe link in the emails. Message and data rates may apply. https://www.edgeinsuranceagency.com/privacypolicy

Area Code

Phone Number

5

Requested by (Your First/Last Names)* This field is required.YOUR first & last names

Your First and Last Names

6

Name and Address of Certificate Holder (Person or entity asking you for insurance)* This field is required.Complete address of PERSON/COMPANY ASKING FOR CERTIFICATE (street, city, state, zip).

7

Email or Fax of Certificate Holder

8

COMMENTS (do you need special endorsements and/or wording; do you need to list your commercial auto, workers’ comp or other policies?)Request here any additional changes to the policy, such as adding Waiver of Subrogation or listing multiple policies on one certificate.

9

Attach and Upload DocumentsUpload copy of insurance requirements, contracts, etc.

Drag and drop files here

Select files to upload

Max. file size: 14.9MB

Copy of contracts, detailed insurance requirements, etc.