Certificate of Insurance Request
Intake Form
Name of person completing this form:
*
First Name
Last Name
Policyholder's Name:
*
Certificate Holder's Name:
*
Certificate Holder's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How do you want the Certificate delivered?
*
Email
Fax
Email Address of Recipient:
Fax Number of Recipient:
Type of Coverage Needed:
*
Proof of Insurance only
Additional Insured for General Liability
Additional Insured for Business Auto Liability
Waiver of Subrogation for General Liability
Waiver of Subrogation for Business Auto Liability
Waiver of Subrogation for Workers Compensation
Other (describe below and attach requirements)
Special Instructions or Wording Needed:
Optional File Upload.
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Example: Insurance Requirements.
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Certificate Disclaimer
Certificates of insurance from our office do not amend, extend or alter the coverage afforded by the policies listed. Policy forms are available upon request for further review.
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