Certificate of Insurance Request
If any questions, please contact us at 718-972-8808
Policy Holder's Name and DBA
*
Name of Insured
Your Policy Number
Requested By
*
First Name
Last Name
Your E-mail Address
*
example@example.com
Phone Number
*
Certificate Holder Information
Name of Certificate Holder
*
Address of Certificate Holder
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email or Fax of Certificate Holder
*
Name certificate holder as Additional Insured
*
Please Select
Yes
No
Additional Insured Name(s)
Please list names of Additional Insured(s); separate additional names with a comma or semi-colon.
File Upload
Upload a File
Drag and drop files here
Choose a file
Copy of contracts, detailed insurance requirements, etc.
Cancel
of
Comments
* By clicking Submit, I understand that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY. Endorsements and/or Special Wording may require additional processing time and/or fee. Correctly completed certificate requests will be processed within two business days.
Submit
Office: (718) 972-8808
Email: info@nymib.com
Address:4315 8th Ave
Brooklyn, New York 11232
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