Certificate of Insurance Request Form
MIG Client Name
DOT Number (Optional)
MC Number (Optional)
Certificate Holder Information
Please complete all the following information.
Certificate Holder Name
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
This is where the COI will automatically be sent.
Broker's Email to Send Cert to
Additional Insured and/or Loss Payee request will need to be sent to email@example.com by the named insured. As this is an Endorsement, please allow time for processing.
Should be Empty: