Certificate of Insurance Form

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 CodePhone 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?*

YesNo
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)?
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:
For residential Jobs
If the job is NEW residential construction, is it condominiums, tract housing, subdivisions, townhouse, tract housing or apartment buildings ?

YesNo
Is the job work for a construction defect claim?

YesNo
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. Cancelof
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.
Should be Empty:

Certificate of Insurance Request

Thank you for the opportunity to assist you!