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