Certificate Request
Business Name
*
This is the name of YOUR company
Business Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Do you have a Contract or Certificate Requirements Document ready to upload?
*
Yes
No
Upload COI requirements document
*
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Choose a file
Cancel
of
You can forward certificate requests to CERTS@DLIAGENCY.COM or fill out the form below.
Coverages Requested (check all that apply)
*
General Liablity
Auto Liability
Excess/Umbrella
Workers Compensation
Other
Certificate Holder Name
*
This will be the person or entity requesting a COI from your company
Certificate Holder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Should this Certificate Holder be named as Additional Insured on the General Liability?
*
Yes
No
I need another certificate holder
Certificate Holder #2 Name
This will be the person or entity requesting a COI from you
Certificate Holder #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Should this Certificate Holder #2 be named as Additional Insured on General Liability?
Yes
No
List of Additional Insureds:
Leave blank if no others are needed
Description of work/request
Is there any special wording or waivers needed on this request?
Yes
No
Special Wording/Waivers Required (Check all that apply)
Primary Wording
30 Days Notice of Cancellation Wording
Waiver of Subrogation (GENERAL LIABILITY)
Per Project Aggregate (GENERAL LIABILITY)
Waiver of Subrogation (COMMERCIAL AUTO)
Waiver of Subrogation (WORKERS COMPENSATION)
Other
Would you like to upload any contract/requirement documents associated with this request?
Yes
No
Upload documents here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Anything else we should know about this request? (Job #, job address, any other special requests, etc)
CLIENT NOTICE:
DLI issues certificates of insurance pursuant to policy terms and conditions only, which may not meet all contract requirements. Some insurance companies require prior approval before DLI is allowed to issue an additional insured endorsement. If your Certificate Holder(s) is requesting an endorsement that requires the insurance company's approval, DLI will need be able to send out a certificate of insurance but will need to wait on the insurance company to send the specific endorsement
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