Certificate of Insurance Request Form

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

CityState / 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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General Information