Certificate of Insurance Request
If any questions, please contact our Certificate Department at (337) 335-0330
Policy Holder's Name and DBA
*
Name of Insured (YOUR business)
Your Policy Number
Your E-mail Address
*
Phone Number
*
-
Area Code
Phone Number
Requested by (Your First/Last Names)
*
Your First and Last Names
Name and Address of Certificate Holder (Person or entity asking you for insurance)
*
Email of Certificate Holder
Does the Certificate Holder want to be named as Additional Insured?
*
Yes
No
Additional Insured Name(s)
Please list names of ALL Additional Insured(s); separate additional names with a comma or semi-colon.
Is there a contractual obligation to name the above additionally insured (If no, explain why needed)?
Please Select
Yes
No
If no, explain why needed?
Detailed Job Description; describe the work the named insured will perform for the additional insured
What is the requested Additional Insured's relationship to you? (General Contractor, Investor, Property Manager etc.)
Job/Project Location
For “Various Locations” – privide city(s) or county(s)
The job is:
Please Select
Industrial
Residential
Commercial
For residential Jobs
Please Select
Remodeling
New Construction
Repair and Service
Room Additions
If the job is NEW residential construction, is it condominiums, tract housing, subdivisions, townhouse, tract housing or apartment buildings ?
Yes
No
Is the job work for a construction defect claim?
Yes
No
COMMENTS (do you need special endorsements and/or wording; do you need to list your commercial auto, workers’ comp or other policies?)
Attach and Upload Documents
Upload a File
Copy of contracts, detailed insurance requirements, etc.
Cancel
of
Thank you for the opportunity to assist you!
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
Should be Empty: