Certificate Request Form

1
Insured's Full Name* This field is required.Please enter the name of the policyholder
First Name
Last Name
2
Insured Company NamePlease enter the name of our insured's business
3
Our Insured's E-mail* This field is required.Please enter the email address of our client
4
Company Name* This field is required.The company who requested the certificate or proof of insurance.
5
Address* This field is required.Please list the address of the company requesting the certificate. Please note that we must have the mailing address for the company requesting the certificate.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
E-mail* This field is required.This MUST be the email address of the company requesting the certificate. It cannot be your own. Please note that a copy of all certificates will automatically be sent to you once sent to the requester.
If a fax number was given, please enter it as xxxxxxxxxx@rcfax.com
7
Phone NumberThe phone number of the company requesting the certificate. we will only use this to contact them if we have problems sending the certificate or need to verify any information.
8
Any Special Endorsments Requested?Is the certificate holder requesting any of the following?
Additional Insured
Waiver Of Subrogation
Hired/Non-Owned Auto
Mortgagee
Lienholder
Losspayee
9
Special Wording Request:Has the company requesting the certificate asked for any special wording to appear on the certificate? Please use this field to provide any special instructions.
10
Do you have a document that specifies the insurance requirements of the requester?It is not required, but will be helpful if you have a document that details the insurance requirements needed for your certificate. Feel free to take a picture of the document with your cell phone by clicking the "upload a file" button below and selecting your phone's camera as the source.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Optional: upload a file if you have a request from your client detailing specific requirements
Cancelof
11
Need Rush Delivery?* This field is required.Certificates of insurance require our team to spend approximately an hour researching the coverage, limits and payment status of your policy prior to sending the certification. Our Standard delivery time is 48 business hours (excluding weekends and holidays). We now offer a rush delivery service If you Need your certificate sent the same day or by 10:00 AM CST the following business day (for requests submitted after 5:00 PM CST)? Your request will be moved to the top of our work list and processed as soon as possible.
Free- Standard deliveryRush Delivery- $20 Fee
12
Rush Delivery* This field is required.Your certificate will be sent the same day or by 10:00 AM CST the following business day (for requests submitted after 5:00 PM CST)? Your request will be moved to the top of our work list and processed as soon as possible.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Rush Delivery
$20.00Edit
Back
Total cost $0.00
First Name
Last Name
13
Invoice ID
Should be Empty: