Certificate of Insurance Request
Clients Name (Account Name)
Account ID
Client Authentication
USDOT
*
Pin
*
Certificate Holder Information:
Company Name
*
dba (If Applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Add Certificate Holder as an 'Additional Insured'?
*
Yes
No
Please keep in mind that there may be Additional Premium applied. Do we proceed and add Ceritificate holder as an Additional Insured without knowing if there is Additional Premium?
*
Yes, proceed without let me know if there is additional premium applied and simply processes and invoice me.
No, Hold and let me know if there is Additional Premium and if there is, what is the Amount and wait for my Approval prior to Proceeding.
Any special wording/verbiage requested to be added to the Certificate of Insurance?
*
Yes (Note: Need to Submit to Underwriting for Approval prior to Applying)
No
Ready to Send Certificate of Insurance (COI)?
*
Yes
No
Certificate Holder's Email
*
example@example.com
Policy AL
Policy MTC
Policy PD
Policy GL
Send COI
Submit Request for Review and Approval
Should be Empty: