AISI - Insurance Certificate Request Form

Certificate of Insurance Request

Please complete the following information to insure your request is handled within our average wait time of: 10 Minutes. Failure to fully complete will delay your receipt of COI. If this form is not working, please send your request to coi@aisiteam.com or fax your request to 888-727-1988.
Insured Information
Insured Name*
Example: ABC Trucking Company LLC
Name of Person Requesting Certificate

First NameLast Name
USDOT Number:
(if applicable)
MC Number:
(if applicable)
Insured's Telephone
Please enter a valid phone number.
Insured's Email
example@example.com
Are you the insured/policyholder needing a copy of your Master Certificate?*

YesNo

Page 2 - Certificate of Insurance Request

Please complete the following information to insure your request is handled within our average wait time of: 10 Minutes. Failure to fully complete will delay your receipt of COI. If this form is not working, please send your request to coi@aisiteam.com or fax your request to 888-727-1988.
Vehicles and Drivers
Include vehicle/trailer on certificate?*

YesNo
Include driver(s) on certificate?*

YesNo
Enter vehicle(s) last 4 digits of VIN to be verified / added to the certificate of insurance. For all scheduled vehicles, please write: ALL
Enter driver's full names to be verified / added to the certificate of insurance. For all scheduled drivers, please write: ALL

Page 3 - Certificate of Insurance Request

Please complete the following information to insure your request is handled within our average wait time of: 10 Minutes. Failure to fully complete will delay your receipt of COI. If this form is not working, please send your request to coi@aisiteam.com or fax your request to 888-727-1988.
Certificate Holder Information
Certificate holder name
Example: Cargo Brokerage Co
Certificate holder DBA:
(if applicablie)
Certificate holder's address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Certificate holder email 1:
COI will be sent to this email
Certificate holder email 2:
COI will be sent to this email
Certificate holder telephone:
Please enter a valid phone number.
Certificate holder fax:
Please enter a fax number to send COI to
Certificate Requirements:

Certificate Holder ONLY - (Ex. Booking Loads)Certificate Holder is an Additional Insured (Optional) - signed contract required upload belowCertificate Holder is a Loss Payee (Optional)Certificate Holder is a Lienholder (Optional)Waver of Subrogation Requested? (Optional)Other
Important:

Additional Insured Requests

Some insurance companies may require a copy of a signed contract/agreement to add Additional Insureds to Liability Policies. The contract/agreement must be signed by both parties (the insured and the additional insured).

Loss Payees

The value of the vehicle/trailer is required.
Description of Operations to add to the certificate (optional):

Page 4 - Certificate of Insurance Request

Please complete the following information to insure your request is handled within our average wait time of: 10 Minutes. Failure to fully complete will delay your receipt of COI. If this form is not working, please send your request to coi@aisiteam.com or fax your request to 888-727-1988.
Any comments? (optional)
Any other additional comments, questions, needs, notes you may want us to know.
File Upload - upload any files you may wants us to review, such as sample COI, Contracts, etc.

Cancelof
Time Submitted

Hour Minutes

AM/PM Option
Should be Empty:

Certificate of Insurance Request

Insured Information

Page 2 - Certificate of Insurance Request

Vehicles and Drivers

Page 3 - Certificate of Insurance Request

Certificate Holder Information

Page 4 - Certificate of Insurance Request